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WU^-^  i- 


A  STUDY 


OF    THE 


TUMORS  OF  THE  BLADDER 


Witli  Original  ContriMtions  and  Drawings 


BY 


ALEX,   W.    STEIN,   M.D., 

SURGEON    TO    CHARITY  HOSPITAL,   GENITO-URINARY   AND    VENEREAL   DIVISION. 

PROF.    OF    VISCERAL   ANATOMY   AND    PHYSIOLOGY   AT    THE    N.    Y. 

COLLEGE   OF   DENTISTRY,    ETC.,    ETC. 


NEW    YORK 
WILLIAM     WOOD     &     COMPANY 

27  Great  Jones  Street 
1881 


Copyright  by 

WILLIAM  WOOD   &   COMPANY, 

1881. 


H.    O.    A     Industrial    School, 
Blectrotypers  and  Printers, 
1S9  E.  76TH  Street. 


PREFACE 


Four  cases  of  tumor  of  the  bladder  have  come 
under  my  observation  within  a  few  years.  Two  of 
these  were  followed  to  their  fatal  termination. 
Both  were  instances  of  primary  cancer;  in  one  case 
the  tumor  was  an  encephaloid,  in  the  other  it  was  a  vil- 
lous epithelioma.  Autopsies  were  fortunately  obtained 
in  both  cases,  the  specimens  were  preserved  and  care- 
fully examined  microscopically  by  Carl  Heitzmann, 
M.D,,  to  whom  also  I  am  indebted  for  the  drawings 
which  accompany  the  histories  of  the  cases  herein 
recorded.  The  other  two  cases,  both  male,  were  only 
temporarily  under  observation  ;  in  one,  the  diagnosis 
was  clearly  made  by  physical  examination  and  then 
the  patient  disappeared  ;  in  the  other,  the  tumor  was 
not  made  out  by  the  touch,  but  the  frequent  micturi- 
tion, blood-tinged  urine,  extreme  tenderness  of  a 
certain  portion  of  the  bladder  to  the  contact  of  in- 
struments, together  with  the  occasional  escape  with 
the  urine  of  floccuient  fleshy  particles,  left  little  doubt 
as  to  the  existence  of  a  vesical  growth.  With  this 
personal  experience  I  began  an  inquiry  as  to  the 
exact  status  of  the  literature  upon  tumors  of  the 
bladder.  Although  our  subject  required  considerable 
research,  having  to  seek  chiefly  in  medical  journals 


iy  TREFACE. 

for  the  information  desired,  the  field  explored  proved 
full  of  interest  and  replete  with  valuable  information. 
I  have  endeavored  to  make  this  monograph  as  com- 
plete as  possible  in  every  practical  detail  bearing  on 
the  nature,  symptomatology,  diagnosis,  and  treatment 
of  the  disease  of  which  it  treats,  and  trust  that  it  may 
prove  of  some  value  as  a  contribution  to  the  surgery 
of  the  bladder. 

Alex.  W.    Stein. 

30  West  Fifteenth  Street, 

Nov.,  1S81. 


CONTENTS. 


PAGE 

Bibliography vii. 

Classification  of  Tumors i 

Fapillomata — Villous  Growths — Structure — Varieties — Nature — Frequen- 
cy— Age — Sex i-6 

Polypi — Varieties — Structure — Frequency — Sex — Age 7-ii 

Carcinomata — Epithelioma — Villous — Encephaloid — Scirrhus   II-13 

Primary  and  Secondary 14-17 

Locality — Age 1 3 

Myoviata — Faye — ^Volkmann — Chiarri 2S-32 

Myo-carc  no-sarcoma,    Billroth 28-29 

Sarcomata — Primary    and   Secondarj^  —  Spindle-celled —  Round-celled  — 

Villous 33-35 

£ony  Tumors 36 

Etiology 36 

Symptomatology. 

Hainaturia — Only  Symptom — Time  of  Appearance — Quantity  of  Blood 

with  Urine — Causes  Producing — Absence  of . . .    36-40 

Irritable  Bladder — First  and  Only  Symptom — Absence   of — Depending 

upon 40-42 

Pain — Absence  of — Location  and  Character  of 42 

Jietention  and  Incontinence  of  Urine 43 

Diagnosis. 
Protrusion   of    Growths   from    }»Ieatus — Spontaneous    Expulsion    of 

Growths 43-44 

Accidental  Removal  of  Growths  by  Catheter 45 

Value  of  Microscopic  Examination  of  Urine  in  Villous  Tumors.    ...       46 

Fibrinuria  as  a  Feature 47 

Value  of  Microscopic  Examination  of  Urine  in  Cancer   48-49 

Physical  Examitiation — Bimanual  Palpation — Introduction  of  Hand  into 

Rectum — Exploration  by  Catheter 50-5 1 

Di'atation  of  Female  Urethra 52-54 

Dilatability  of  Female  Urethra — Digital  Exploration  of  the  Interior  of 
Bladder 56-57 

Differential  Diagnosis  between  Benign  and  Malignant  Growths — Between 

Calculi  and  Tumors ,  .  .57-59 


vi  CONTENTS. 

Duration  and  Prognosis. 

Non-malignant — Malignant  Tumors   60-62 

Treatment. 

Operations  performed  on  Females 63-71 

Operations  performed  on  Males I'^-'l 

Results  of  Operations  on  Females 11^19 

Results  of  Operations  on  Males 79~So 

Methods  of  Operating 07t  Females — Bloodless  Dilatation  of  Urethra — Inci- 
sion of  Urethra — Kolpo-cystotomy S2-83 

Methods  of  Opei-atiiig  on  Males — Perineal  Cystotomy — Supra-pubic  Cys- 
totomy— With  or  without  Cystorrhaphy S4-S9 

Avoidance  of  "Wounding  Peritonseum — Prevention  of  Urinarj'  Infiltra- 
tion— Urethral  Drainage  by  Suction S6-90 

Palliative  Treatment — General  and  Local  Astringents — Anodynes — Injec- 
tion of  Bladder  by  Hydrostatic  Pressure 91-92 

Conclusions - 93 

Illustrations. 

Benign  Villous   Tumors — Hudson 5 

Microscopic  Appearance  of  Same 6 

Polypus — Fleming  S 

Fibrous  Polj-pus — Gersuny. 10 

Medullary  Cancer — Original 21 

Microscopic  Appearance  of  Same 22 

Villous  Cancer — Original 26 

Microscopic  Appearance  of  Same : . . .  27 

Myo-carcino-sarcoma — Biilroth 30 

Myoma — Volkmann 31 

Female  Urethral  Dilator,  Original 55 

Forceps  and  Scissors — Simon 82 


BIBLIOGRAPHY. 


1747.  Warner.     Polypus.     Cases   in  Surgery,  4th  edition,  17S4; 

and  Philosophical  Transactions,  1790. 
1797.  Baillie.     Polypus.     Morbid  Anatomy. 
1800.  Walter.     Polypus.     i\Iedico-Chir.  Trans.,  vol.  41. 
1817.  Langstaff.     Cancer.     ]vIedico-Chir.  Trans.,  vol.  8. 

1822.  Bingham.     Cancer.     Diseases  of  Bladder. 

1823.  Le  Cat.     Fungus.     Howship,  Urinary  Organs. 

1830.  Dessault.     Polypus,  Villous.     Chopart,  Maladies  des  Vois 
Urinaires,  2  vols. 

1834.  Pleininger.     Papilloma.    Wiirtemberg  Med.  Corr.  Blatt,  No. 

23- 
Civiale.     Gaz.  de  Med.,  Paris,  No.  52. 

1835.  Crosse.     Polypi.     Formation,  etc.,  Urinary  Calculi. 

1836.  Springall.     Villous.     Guy's  Hosp.  Rep.,  series  i,  vol.  i. 

1838.  Hutchison.     Fungoid.     Med.-Chir.  Rev.,  vol.  vi. 
Willis.     Pendulous  Growth.     Urinary  Diseases,  London. 

1839.  Langstaff.     Fungus.     Zvled.-Chir.  Rev.,  vol.  iii. 
Mendalgo.     Cancer.     Giornal  di  Venezia,  Maggio,  Junio. 

1842.  Barlow.     Fungus.     Guy's  Hosp.  Rep.,  series  i,  vol.  vii. 
Warner,  by  Douglass.     Villous.     Lon.  Med.  Gaz.,  February. 
Douglass.     Tumor. 

Howship,  by  Douglass. 

Civiale.     Maladies  des  Org.  Genito-Urinaires. 

1843.  Contini.     Cancer.     Annal.  Med.  Chir.  del  Metaxa,  vol.  9. 

1845.  Theinemann.     Polypus.     Amer.  Journ.  Med.  Sc,  July. 
Vache.     Polypi.     L'Experience,  No.  327,  October. 

1846.  Bulley.     Fungus.      London  Times,  August  ist. 

1847.  Bentley,  for  Kingdon.      Carcinoma.      Trans.    Path.  Soc. 

London,  vol.  i. 


A-IU 


BIBLIOGRAPHY. 


1847.  Hiltscher.     Carcinoma.     Oest.  Med.  Wochensch.,  No.  46. 
1S49.  Kestevan.     Fungoid.     London  Med.  Gaz.,  November. 

185 1.  Beith.     Cancer.     Trans.  Path.  Soc,  London,  vol.  iii. 
Holthouse.  Fungus.  "         "         "  "         March  i8th. 

1 85 2.  Stanlej^,  by  Savory.     Polypus.     London  Times  and  Gaz., 

July  31st. 
1854.  Gibbon.  Cancer.  Trans.  Path.  Soc,  London,  vol.  v.,  series  2. 
Shaw.     Villous.         " 
Holt.     Cancer. 
Thompson.   Cancer.  "         " 
Hutchinson.       "       " 


Ohm.     Tumor.     Deutsche  Klin.,  24. 

1855.  Pollock.     Cancer.     Trans.  Path.  Soc,  vol.  6. 
Gibb.  "  "  "         "         "    6. 

1856.  Sibley.     A^illous.  "  "         "         "     7. 

1 85 7.  Stewart,  by  Hutchinson.  A-^illous.   London  Times  and  Gaz., 

May  2d. 
Lloyd,  by  Hutchinson.     Tumor.     London  Times  and  Gaz., 

May  2d. 
Cock,  by  Wilkes.    Villous.     Lon.  Times  and  Gaz.,  May  9th. 
Partridge.  "  "         "         "       "         "     2d. 

Hooper.  "  "         "         "       "         "      " 

Thompson.  ''       Trans.  Path.  Soc,  London,  vol.  8. 

Ellis.    Cancer.    Boston  Med.  and  Surg.  Journ.,  January  22d. 
Jackson.    "  "         "         "        "         "  "       29th. 

1858.  Lambl.     Villous  Cancer.     Virchow's  Arch.,  Bd.  xv. 

1859.  Paulus.     Cancer.     Zeitschr.   f.  Chir.   u.   Geburtsh.,  xi.,  14, 

p.  264. 
i860.  Coulson.     Cancer.     London  Lancet,  August  25th. 

Clarke.  "  London  Times  and  Gaz.,  August  iSth. 

Bryant,  by  Hicks.     Villous.     Trans.   Path.  Soc,  London, 

vol.  xi. 
Senftleben.     Sarcoma.     Arch.  f.  Klin.  Chir.,  Bd.  i.  Heft  i. 
Watson.     Villous  Cancer.     Edinb.  Med.  Journ.,  June. 
Hilton.     Polypi.     J.  Cooper  Foster's  Surgical  Diseases  of 

Children. 
Gibb.     Cancer.     Trans.  Path.  Soc,  London,  vol.  xi. 


BIBLIOGRAPHY.  ix 

1862.  Bernadet.     Fungus.     Bull,  de  la  Soc.  Anat.,  April. 
O'Connor.     Cancer.      Trans.  Path.  Soc,  London,  vol.  xiii. 
Heath.  "  "  "         "  "  "       " 

1863.  Brown.     Villous  Cancer.     Edinb.  Med.  Journ.,  May. 
Sage.     Cancer.     British  Med.  Journ.,  February  7th. 
Rankin.     Epithelioid.     British  Med.  Journ.,  August  22d. 
Holmes.  "  Trans.  Path.  Soc,  London,  vol.  xiv. 

1864.  Holmes  Coote.     Cancer.     Med.-Chir.  Trans.,  vol.  47. 
Nash.     Villous.     British  Med.  Journ.,  March  26th. 
Sanders.     Cancer.     Edinb.  Med.  Journ.,  September. 

1S65.  Potain.     Polypus.     Gaz.  des  Hop.,  No.  15. 

1867.  Ramskill.     Growth.     British  Med.  Journ.,  June  ist. 
Bastian.     Scirrhus.     Trans.  Path.  Soc,  London,  vol.  18. 
Thompson.  Villous.        "  "         "  "  "      " 

Cancer.        "  "         "  "  "       " 

Fleming.  "  Genito-Urinary  Diseases. 

Polypus. 
Encephaloid.  " 

1868.  Hicks.     Tumor.     London  Lancet,  May  30th. 
Guersant.     Polypus.     Gaz.  des  Hop.,  No.  23. 

Nunn.     Villous  Epithelioma.     Trans.  Path.  Soc,  London, 

vol.  19. 
Birkett.     Polypi.     Med.-Chir.  Trans.,  vol.  41. 
Hewitt. 

Cooper.  "  "         "  "  "      " 

Petit.  "  "         "  "  "      " 

1869.  Heilborn.     Krebs.     Inaug.  Diss.,  Berlin. 

Dickenson.     Cancer.     Trans.  Path.  Soc,  London,  vol.  20. 

1870.  Reeves.    Polypus.     Boston  Med.  and  Surg.  Journ.,  August 

25th. 
Anderson.     Cancer.     British  Med.  Journ.,  January  22d. 
Murchison.     Villous.     Trans.  Path.  Soc,  London,  vol.  21. 
Thompson.     Vascular  Tumor.    "         " 
Jackson.    Polypus.    Boston  Med.  and  Surg.  Journ.,  August 

25th. 

1871.  Faye.     Fibro-myoma.     Schmidt's  Jahrb.,  Bd.  53, 
Guillon.     Polypi.     Pitha-Billroth,  allg.  u.  spec.  Chir.,  Bd. 

3,  Abt.  2. 


X  BIBLIOGRAPHV. 

1872.  Smyth.     Cancer.     British  Med.  Journ.,  July  20th. 
Ashhurst.       ''  Philadelphia  Med.  Times,  April  15th. 
Bishop.     Polypus.     Gross'  Surg.,  Philadelphia. 
Gersuny.     Polypus.     Arch.  f.  Klin.  Chir.,  Bd.  13. 
Galignani.     Villous  Cancer.     Luglio.  ann.  univer.,  p.  127. 

1873.  Guilhaud.     Cancer.     These    sur  I'anat.  etc.  de  la  Vessie, 

Paris. 

1874.  Marsh-Beck.     Polypoid.     Trans.  Path.  Soc,  London,  vol. 

XXV. 

1875.  Simon.     Polypi.     Arch.  f.  Klin.  Chir.,  vol.  18. 
Billroth.    Myo-sarc.  and  Myo-carcin.    Arch.  f.  Klin.  Chir., 

vol.  18. 
Wilkes.     Villous.     Wilkes  and  Moxon,  Path.  Anat. 
Bryant.  "  Bryant's  Surg. 

Freund.     Cancer.     Virchovv's  Arch.,  Bd.  64. 
Goetz.  Cancer.     Bull,  de  la  Soc.  Anat.,  Paris,  November. 
Herrgott.    Tumor.     Rev.  Med.  de  I'Est,  September,  p.  141. 

1876.  Mass.     Polypi.     Berlin.  Klin.  Wochenschr.,  No.  4. 
Kocher.     Papilloma.     Centralbl.  f.  Chir.,  April  ist. 
Volkmann.     Myoma.     Arch.  f.  Klin.  Chir.,  Bd.  ix. 
Schatz.     Fibro-myxoma.     Arch.  f.  Gynakol.,  Heft  x. 
Chambard.     Cancer.     Bull,  de  la  Soc.  Anat.,  November. 
Boyer.  "  "         "       " 

Poisson.     Fungus.  "         "       "  "       February. 

Langlebert.     "  "         "      "  "       March. 

a  a  J         II  u         a  u  a 

Levertin.     Cancer.     Hygiea,  38,  October. 
"  Fibroma.      "  December. 

1877.  Fagg.     Epithelioma.    Two  cases.    Trans.  Path.  Soc,  Lon- 

don, vol.  28. 

Butlin.     Scirrhus.     Trans.  Path.  Soc,  London,  vol.  28. 

Winckel.     Papilloma.     Billroth's  Handbuch  Frauenkrank. 

Brainwell.     Cancer.     London  Med.  Times  and  Gaz.,  De- 
cember 22d. 

1878.  Alexander.     Villous.      London  Lancet,  August  17th. 
Stimson.     Sarcoma.     New  York  Med.  Record,  November 

26th. 
Ultzmann.     Villous.     "  Ueber  Hematuria. " 


BIBLIOGRAPHY.  xi 

1878.  Marchand.     Sarcoma.     Arch,  f.  Klin.  Chir.,  Bd.  xxii. 

Cancer.  "  "         "        "       " 

Harrison.     Encephaloid.     On  Urinary  Organs. 

Villous  Cancer. 
Avezon.     Cancer.     Bull,  de  la  Soc.  Anat.,  February. 
Phillipart.       "  Presse  Med.,  xxx.,  No.  22. 

1879.  Humphry.     Papilloma.     Med. -Chir.  Trans.,  vol.  62. 
Norton.  "  Two  cases,  British  Med.  Journ., 

May  31st, 

Heath.     Villous  Sarcoma.     London  Times  and  Gaz.,  De- 
cember 13th. 

Hudson.     Polypi.     Dublin  Med   Journ.,  June. 

Morris.  "  British  Med.  Journ.,  May  31st. 

Bryant.     Growth. 

Godson.     Polypus.         "         "  "     April  26th. 

Brenneke.     Fibro-myxoma.     Arch.  f.  Gynakol.,  April  12th. 

Thornton.     Sarcoma.     British  Med.  Journ.,  May  31st. 

Sanger.     Secondary  Sarcoma.    Arch.  f.  Gynakol.,  Bd.  xvi. 

Ahlfeld.  "  "  "  "  "      " 

1880.  Marcacci.     Villous.     London  Medical  Record,  May  15th 

and  December  15th. 
Davies-CoUey.     Villous.     London  Lancet,  December  i8th. 
Hicks.    Cauliflower-like  Mass.     London  Lancet,  May  30th. 
Soltmann.     Secondary  Sarcoma.     Jahrb.  f. ,  Kinderhlkde., 

Bd.  xvi.,  H.  3  and  4. 

1881.  Barton.     Care.  Papilloma.     Dublin  Journ.  Med.  Sc,  Feb- 

ruary. 
Treves.     Villous.     London  Lancet,  April  30th. 
Davies-Colley.       Shaggy    Epithelioma.      London    Lancet, 

April  30th. 
Hill.     Epithelioma.     British  Med.  Journ.,  May  14th. 

Villous. 
Lancaster.     Cancer.     Coulson's  Diseases  of  Bladder. 
Coulson. 

Belfield.     Myoma.     Wien.  Med.  Wochenschrift,  May  19th. 
Thomson.     Myxoma.    British  Med.  Journ.,  March  12th. 
Stein.     Villous  Cancer. 
"         Encephaloid. 


TUMORS  OF  THE  BLADDER 


Tumors  of  the  bladder  may  be  classified  as  follows : 

r  Papillomata,  or  villous  growths. 

„      .        „  ,  Myxomata,  or  mucous  polypi. 

Benig-n  Growths.     -{  -r-^  .  m.  i      • 

*=  Fibromata,  or  nbrous  polypi. 

Myoraata. 

f  r  Epithelioma,  villous. 

A/r  T      '*.  r-         4.-U       I  Carcinomata.  J.  Encephaloid. 
Malign  t  G-rowths.  ■<  \  ^        ^ 

I  i  Scirrhus. 

1^  Sarcomata. 

I  have  brought  together  and  classified  sixt}'  cases  of 
benign  papillomatous,  villous,  and  polypoid  growths.  In 
addition  to  these,  I  find  casual  mention  made  of  a  few 
cases  said  to  have  been  recorded  by  the  older  writers 
(Lusitanus,  Sylvius,  Kirchner,  Rolin,  Collison),  but  of 
these  I  have  no  data.  Again,  our  numbers  might  be  still 
further  increased  by  the  addition  of  a  few  cases  undoubt- 
edly benign,  but  which,  being  simply  designated  as  fungi^ 
without  further  description  as  to  structure,  etc.,  could  not 
be  properly  classified,  and  were  excluded. 

PAPILLOMATA,    OR   VILLOUS    GROWTHS. 

These  tumors,  as  their  name  indicates,  present  usually 
the  characters  of  a  true  villous  structure,  closely  resembling 
the  villi  of  the  chorion.  To  be  appreciated,  they  must  be 
examined  under  water;  when  out  of  water,  they  collapse 


2  TUMORS    OF    THE    BLADDER. 

into  a  comparative!}-  small  bulk,  but  placed  in  water,  the  vil- 
losities  are  floated  out  and  present  a  beautiful  and  charac- 
teristic appearance :  the  larger  villi  branch  out  from  the 
central  mass,  and  from  these  smaller  villi  are  seen  sprouting- 
out,  and  from  these  again  still  smaller  ones  often  arise.  The 
form  of  the  villi  is  variable,  some  being  thick  and  short, 
others  long,  club-shaped,  and  others  still  long  and  filament- 
ous. In  minute  structure,  each  villous  is  composed  of  a 
capillarv  loop,  covered  bv  a  scanty  epithelial  investment, 
which  does  not  grow  within  the  delicate  framework  of 
connective  tissue  (see  Plate  ii.,  Fig.  2). 

There  are  several  varieties  of  villous  growths  which 
vary  in  shape  and  appearance. 

They  may  present  as  numerous  villous  processes  without 
a  distinct  tumor,  that  is,  the  villi  grow  directly  from  the 
mucous  membrane  without  an)-  base.  This  was  well 
shown  in  a  case  of  Mr.  Murchison  ;  the  base  of  the  blad- 
der and  portion  surrounding  the  orifice  of  the  ureters 
was  studded  with  numerous  long,  delicate,  villous  proces- 
ses, nowhere  forming  a  distinct  tumor,  and  his  case  is 
further  interesting  in  that  on  the  mucous  lining  of  the 
pelvis  and  cahxes  of  both  kidneys  were  also  found  numer- 
ous long  villous  processes.  They  were  from  one  to  sev- 
eral lines  in  length,  covered  externally  with  a  thin  layer  of 
epithelium,  and  included  a  capillary  vessel  full  of  blood. 
Mucous  lining  of  ureters  was  free  from  disease.  Death 
was  caused  from  uraemia  due  to  obstruction  of  ureters  by 
clots  of  blood  derived  from  the  villous  processes  above. 

Some  of  these  growths  appear  as  pendulous  tumors 
hanging  from  the  mucous  membrane  by  a  distinct  stalk, 
or  pedicle,  and  terminate  in  numerous  filamentous  proces- 
ses (see  Plate  i.).  Others  are  sessile,  and  occur  somewhat 
less  frequently  than  the  preceding  variet}'.  They  may 
appear  either  as  soft,  loose,  shaggy,  villous  tufts,  project- 
ing more  or  less  from  the  mucous  surface,  or  they  may 


TUMORS    OF    THE    BLADDER.  3 

have  a  more  solid  basis  structure,  and  present  a  warty  or 
cauliflower-like  appearance. 

Villous  tumors  of  the  bladder  have  long  been  regarded 
as  malignant  in  their  nature,  principally,  perhaps,  on  the 
authority  of  Rokitansky,  who  wrote  an  essay  on  this  sub- 
ject, an  abstract  of  which  can  be  found  in  Paget's  lectures 
on  Surgical  Pathology,  vol.  2.  And  while  it  cannot  be 
denied  that  malignant  growths  do  sometimes  take  on  a 
villous  character,  or  that  simple  villous  growths  may 
become  malignant,  examples  of  which  we  find  both  among 
carcinomata  and  sarcomata,  such  growths  are  rare.  A  care- 
ful study  of  the  cases  I  have  collated  will  show  that  villous 
growths  are  usually  benign.  In  structure,  they  do  not 
partake  of  the  character  of  malignant  tumors.  In  their 
origin  and  in  the  manner  of  their  development,  they  are  as 
innocent  growths.  The  course  and  duration  of  the  com- 
plaint is  not  in  accordance  with  that  generally  observed  in 
malignant  disease.  They  are  strictly  local,  do  not  invade 
adjacent  tissues,  there  is  no  glandular  involvement,  and 
there  are  no  secondary  deposits  occasioned  in  other  or- 
gans of  the  body.  They  do  not  cause  death  from  malig- 
nant cachexia,  but  from  hemorrhage  or  from  the  conse- 
quences of  mechanical  obstruction  to  the  outflow  of  urine. 
■  These  facts  are  very  evident  after  a  careful  study  of  the  his- 
tory, course,  symptoms,  and  termination  of  many  cases  of 
villous  disease  on  record. 

I  have  collated  thirty  cases  of  papillomatous  or  villous 
growths.  Sixteen  occurred  in  the  female  and  fourteen  in 
the  male,  that  is,  the  frequency  of  occurrence  in  the  two 
sexes  was  about  equal.  With  respect  to  age,  the  youngest 
subject  was  two  and  three-quarter  years  old,  in  two 
others  the  subjects  were  impubic.  After  that,  however, 
none  appeared  before  the  age  of  thirty-two.  Seventeen 
were  between  thirty-two  and  fifty  years  of  age.  The 
oldest  patient  was  seventy.  Villous  growths  are  as  often 
multiple  as  single ;  the  two  classes  of  cases  were  found  in 


^  TUMORS    OF    THE    BLADDER, 

just  equal  proportion.  As  many  as  twelve  distinct  tumors 
were  found  in  one  case,  and  in  several  the  vesical  walls 
were  said  to  be  studded  with  numerous  villous  growths- 
They  are  more  frequently  pedunculated  than  sessile.  They 
are  generally  small,  but  vary  in  size  from  that  of  a  pea  to 
a  goose  egg,  or  a  small  orange  ;  and  in  one  of  Simon's 
cases  the  papilloma  filled  two-thirds  of  the  cavity  of  the 
bladder  which  he  successfully  removed  b}'  the  scoop. 
They  are  very  rarely  situated  on  the  anterior  wall.  Their 
usual  point  of  attachment  is  the  trigone  and  near  the  ure- 
ters ;  of  the  two  openings,  the  right  ureter  by  predilection. 

An  interesting  and  typical  case  of  benign  villous  growths 
is  reported  by  Dr.  R.  S.  Hudson  in  the  Dnl?.  Joiirn.  Med. 
Sc,  June,  1879,  fjfom  which  our  Plates  i.  and  ii.  are  taken. 
The  structural  character  of  these  simple  tumors  is  here 
well  shown,  and  may  be  examined  in  contrast  with  the 
microscopical  appearances  of  villous  epithelioma  as  shown 
in  our  original  drawing  (Plate  viii.). 

Plate  i..  Fig.  i.  Bladder  half  original  size.  Dr.  Hudson 
says,  "  It  will  be  seen  that  there  are  eight  tumors,  each  con- 
nected b}"  a  narrow  pedicle,  which  might  be  ligatured, 
avulsed,  or  treated  with  the  ecraseur.  The  large  tumor  at 
the  fundus  has  been  reflected  so  as  to  show  more  distinctly 
the  pedicle  from  which  it  springs.  All  were  coated  with 
2.  thick  layer  of  phosphatic  deposit  like  brownish  mortar. 
When  this  layer  was  removed  and  a  portion  of  the  tumor 
floated  out  in  water,  its  true  character  was  seen :  delicate, 
lace-like  growths  springing  from  a  firm,  fleshv  pedicle. 
To  the  right  will  be  seen  the  enlarged  projecting  bundles 
of  anh3'psrtrophied  bladder  not  unlike  the  column::e  carneEe 
of  the  ventricles  of  the  heart.  The  openings  of  the  ureters 
may  be  seen,  but  the  ureters  themselves,  owing  to  the 
obstructed  flow  of  urine,  were  dilated  to  the  size  of  the 
cesophagus." 

Plate  ii..  Fig.  i  represents  a  portion  of  the  tumor  under 
an  inch  object-glass. 


TUMORS   OF   THE   BLADDER. 


V 


^>.  ''p)i.:J 


Plate  I.— Eight  benign  villous  growths.    Case  of  Dr.  R.  S.  lludion—Dud- 
lin  Medical  J otirnaL 


TUMORS   OF   THE    BLADDER. 


Plate  II.     Fig.  i. 


WinA  X  40  diam. 


I' 


W^M 


W. 


f  A 


Fig.  2 
(=  A,  Fig.  I, 
X  310  diam.). 


Microscopic  appearances  of  Dr.   Hudson's  benign  villous  growths. — Dublin 
Medical  yournal. 


TUMORS   OF    THE    BLADDER.  7 

Fig.  2,  A  portion  of  the  same  under  a  quarter  of  an 
inch  object-glass.  "  The  thin-walled  capillary  vessels  of 
irregular  diameter  may  be  seen  coursing  through  the 
growth,  the  whole  surface  being  covered  with  a  columnar 
or  polygonal  epithelium.  The  epithelium  is,  however,  on 
the  surface,  homologous;  not  within  the  subjacent  connective 
tissue,  heterologous,  which  is  characteristic  of  epithelioma- 
tous  growths." 

POLYPI. 

The  mucous  polypus  or  benign  myxoma  is  a  soft,  smooth, 
succulent,  oedematous-looking,  pediculated  growth,  resem- 
bling nasal  polypus.  It  grows  from  the  mucous  surface, 
and  is  composed  chiefly  of  the  elements  of  that  structure, 
with  a  stroma  of  loose  connective  or  filamentous  tissue. 
The  structure  of  the  fibrous  polypus  is  indicated  by  its 
name  ;  it  is  firmer  and  more  fleshy  or  fibrous  in  consistence 
than  the  mucous  polypus-,  has  a  reddish-blue  or  dark-red 
color,  and  proceeding  from  the  submucous  connective 
tissue,  it  pushes  the  mucous  membrane  before  it.  These 
tumors,  mucous  and  fibrous,  project  into  the  interior  of 
the  bladder  either  as  long  pendulous  bodies  (PI.  iii.)  or  as 
globular,  pyriform,  or  irregularly-shaped  outgrowths. 

Of  the  polypoid  growths,  mucous  and  fibrous,  I  have 
found  thirty,  which  shows  that  these  growths  are  not 
as  rare,  compared  with  the  papillomata,  as  is  generally 
believed ;  the  two  classes  of  growths  appearing  nearly  in 
an  equal  number  of  cases.  With  respect  to  sex,  our  num- 
bers are  almost  equally  divided,  sixteen  being  male  and 
fourteen  female.  While  polypi  may  occur  in  advanced 
life,  one  having  presented  at  the  age  of  seventy-three, 
they  are  generally  found  at  an  earlier  period  of  life  than 
any  other  kind  of  tumor.  Especially  is  this  true  of  mucous 
polypi  which  have  occurred  at  the  ages,  respectively,  of 
five,  two,  and  two  years ;  twenty-two,  eighteen,  and  thirteen 
months.    Winckel  found  two  mucous  polypi  in  the  bladder 


TUMORS   OF   THE   ELADDER. 


Plate  III. 


Polypus,  from  Christopher  Fleming's  "  Diseases  of  Genito- Urinary  Organs.' 


TUMORS   OF   THE   BLADDER.  o 

of  a  female  child  who  died  thirty-six  hours  after  birth  ; 
one  was  situated  at  the  superior  fundus  (an  exceptional 
position) ;  was  very  vascular,  soft,  pediculated,  semi-glob- 
ular, and  somewhat  larger  than  a  pea  ;  the  other,  a  smaller, 
growth,  came  from  the  lower  portion  of  the  bladder. 

Polypi  are  by  far  more  frequently  single  than  multiple. 
In  size  they  vary  from  a  nut  to  that  of  the  fist.  From 
Jackson's  patient  a  piece  was  removed  the  length  of  the 
finger,  and  after  two  days,  another  piece,  eight  inches  long 
and  thick  as  the  thumb,  was  twisted  off.  In  their  manner 
of  attachment  they  are  occasionally  peculiar.  In  one 
instance  (Stanley)  the  growth  stretched  transversely 
across  the  fundus,  behind  the  aperture  of  the  ureters,  and 
was  attached  on  either  side,  but  free  in  the  centre.  In 
another  (Thompson)  there  were  two  growths,  each  the  size 
of  a  small  fig,  with  a  slender  stalk,  one  and  a  half  inches 
long,  which  joined  to  form  a  common  pedicle  connected 
with  the  trigone.  In  a  third  (Petit),  a  pyramidal-shaped 
tumor  the  size  of  the  fist  was  attached  by  a  very  delicate 
pedicle.  In  still  another  (Thomson),  the  cavity  of  the 
bladder  was  almost  obliterated  by  a  myxoma.  From  the 
upper  and  right  side  of  the  cavity  hung  a  mass  resembling 
a  bunch  of  Hambvirg  grapes.  Like  the  papillomata  in 
their  point  of  attachment,  they  have  a  predilection  for  the 
trigone,  and  are  probably  found  more  frequently  near  the 
urethral  orifice  than  the  former. 

Pure  fibrous  tumors  are  not  common.  Gersuny  relates 
a  very  interesting  case  of  vesical  turnor  in  a  man  aged 
forty-nine,  which  he  attempted  to  remove  by  perineal  cys- 
totomy, but  failed.  The  man  died,  and  at  the  bas-fond 
towards  the  right  there  was  found  projecting  into  the 
bladder  a  diverticulum  with  an  inclosed  tumor.  A  quite 
wide  orifice  communicated  with  the  interior  of  the  cyst, 
the  edges  of  which  being  pushed  back,  a  firm  elastic  tumor 
about  the  size  of  a  hen's  egg  fell  out.  It  was  nearly  glob- 
ular, with   a   smooth    surface,    having,  however,   several 


10  TUMORS   OF    THE    BLADDER. 

converging  furrows  leading  to  a  point,  from  which  origi- 
nated a  pedicle  one  and  a  half  inches  long,  and  not  the 
diameter  of  a  quill  (Tl.  iv..  Fig.  2).  The  tumor  which  was 
attached  to  the  interior  of  the  diverticulum  was  torn  off 
b}'  very  slight  fraction.  The  vertex  of  the  bladder  was 
found  to  be  in  communication  with  a  pus  cavity  above, 
and  this  again  with  another  cavity  containing  a  stone  the 
size  of  a  walnut,  egg-shaped,  weighing  two  drachms,  and 
having-  for  its  nucleus  the  broken  end  of  a  catheter  (PL 
iv.,  Fig.  i).  A  represents  the  abscess  cavity,  which  com- 
municates posteriorly  with  the  bladder,  V,  and  anteriorly 
with  the  cavity  containing  the  stone,  C.  D  shows  the 
diverticulum,  which  projects  with  its  contained  tumor 
into  the  cavit}^  of  the  bladder.  At  F  is  the  opening  into 
the  diverticulum,  through  which  a  portion  of  the  tumor  is 
seen.  The  tumor  consisted  of  undulating  connective 
tissue  and  numerous  spindle  cells,  with  round  nuclei. 
This  patient  had  suffered  with  blennorrhoea  for  eight  years, 
and  gave  history  of  having  had  retention  of  urine  several 
times,  the  last  time  requiring  supra-pubic  puncture,  which 
opening  was  not  allowed  to  heal  for  three  weeks.  Some 
time  after  the  puncture  was  made,  one  day,  while  cathe- 
terizing  himself,  an  inch  of  the  distal  end  of  a  flexible 
catheter  broke  off  and  remained  lodged  in  the  urethra,  as 
he  said,  just  behind  the  scrotum.  Attempts  to  remove  the 
same  proved  ineffectual.  This  case  is  remarkable  :  first,  in 
the  peculiar  development  of  the  tumor  ;  second,  in  the 
formation  of  a  diverticulum  at  the  vertex  of  the  bladder, 
occasioned,  no  doubt,  by  the  supra-pubic  puncture  ;  and 
third,  in  the  wandering  of  the  catheter  fragment  into  this 
cavity  and  forming  the  nucleus  for  a  stone. 

Somewhat  analogous  to  the  above,  as  regards  the  exist- 
ence of  an  abscess  cavit}^  in  connection  with  the  bladder, 
is  the  case  of  Stanley.  Here  the  growth  was  so 
situated  as  to  fall  over  and  obstruct  the  urethra  in 
the  act  of  micturition,  and  the  urine  being  driven  into  the 


TUMORS   OF   THE   BLADDER. 


II 


Plate  IV.     FiG.  i 


Fibrous  pol>'pus  inclosed  in  a  diverticulum. —Gersuny,  Arch.f.  kl  Chir.,  Bd.13. 


j2  TUMORS   OF   THE   BLADDER. 

imperfectly-closed  orifice  of  the  urachus,  this  tube  was 
gradually  reopened  until  the  urine  reached  the  vicinity  of 
the  umbilicus,  where  an  abscess  formed,  which,  being 
opened,  gave  exit  to  both  pus  and  urine,  and  for  a  number 
of  days  before  death  all  the  urine  was  discharged  through 
the  opening  in  the  abdominal  wall.  The  patient  was  a 
male  child,  aged  thirteen  months. 

Gersuny  also  mentions  and  gives  the  drawing  of  a 
cysto-fibroid,  which  was  found  post-mortem  by  Prof. 
Ernst  in  the  bladder  of  a  boy  aged  fifteen.  The  tumor 
was  of  the  size  of  an  apple,  and  attached  by  a  thin  pedicle 
to  the  fundus. 

CARCINOMATA. 

Cancer  of  the  bladder  may  present  under  the  forms  of 
epithelioma,  encephaloid,  villous,  and  scirrhus,  and,  as  I 
believe,  in  the  order  of  frequency  mentioned.  Upon  this 
matter,  however,  a  very  wide  discrepancy  of  opinion  pre- 
vails among  writers.  I  need  only  refer  to  such  eminent 
authorities  as  Gross  and  Coulson,  who  have  most  recently 
written  on  the  subject.  The  former  says  :  "  The  usual  vari- 
ety of  carcinoma  met  with  in  the  bladder  is  the  epithelial ; 
what  was  formerly  known  as  scirrhus,  is  nothing  more  than 
the  firm,  infiltrating  form  of  epithehoma.  .  .  .  The  encepha- 
loid form  is  of  the  same  nature,  but  its  stroma  is  more  deli- 
cate and  more  vascular."  On  the  other  hand,  Coulson  says  : 
"  Encephaloid  is  the  most  usual  form,  scirrhus  has  occurred 
less  frequently,  and  only  a  few  cases  of  epithelioma  have 
been  placed  on  record."  It  is,  unfortunately,  impossible  to 
reconcile  these  opposite  statements.  Our  researches  do 
not  accord  with  the  view  expressed,  "  that  only  a  few  cases 
of  epithelioma  have  been  placed  on  record."  On  the  con- 
trary, it  would  seem  that,  taking  vesical  tumors  collec- 
tively, epithelioma  exists  in  at  least  a  good  percentage  of 
cases.  With  regard  to  the  propriety  of  designating  the 
cancers  as  epithelial,  encephaloid,  and  scirrhus,  it  may  be 


TUMORS    OF   THE    BLADDER. 


13 


said  that  these  terms  have  at  least,  clinically,  not  been 
abandoned,  and  if  there  is  any  foundation  for  such  a  classi- 
fication, it  applies  for  tumors  pf  the  bladder  as  well  as  for 
other  parts  of  the  body.  This  is  shown  by  the  variation 
vesical  tumors  present  in  regard  to  their  mode  of  growth, 
histological  characters,  clinical  history,  etc.  For  example, 
descriptive  of  epithelioma,  we  have:  ist.  One  or  more 
small,  submucous,  circumscribed  nodules,  or  points  of 
induration.  In  a  primary  cancer  (Thompson),  there  were 
five  or  six  masses,  varying  in  size  from  a  pea  to  a  horse 
bean,  and  unconnected  with  each  other.  2d.  It  may  pre- 
sent as  an  ulcerated  surface,  with  elevated  and  indurated 
edges.  In  Nunn's  patient,  there  was  a  large,  ragged  ulcer, 
and  only  the  anterior  third  of  the  walls  of  the  bladder  was 
free  from  epitheliomatous  disease.  In  several  of  our  cases, 
the  epithelial,  or  so-called  "bird's  nest"  aggregations,  so 
characteristic  of  epithelioma,  is  distinctly  mentioned,  and 
with  the  exception,  perhaps,  of  the  enlargement  of  abdom- 
inal glands,  there  is  in  these  cases  no  secondar}^  deposition 
of  cancerous  material. 

Corresponding  to  the  encephaloid  variety,  we  have  the 
history  of  a  more  rapid  disease,  a  decided  tumor  project- 
ing into  the  interior  of  the  bladder,  often  attaining  an 
enormous  size,  with  a  soft  sprouting,  fungoid,  or  cauli- 
flower-like appearance,  and  in  structure  composed  of  an 
abundance  of  cellular  elements,  with  a  scanty  stroma.  In 
some  instances,  the  tumor  was  found  broken  down  in  fatty 
and  caseous  degeneration,  and  presented  a  dirty,  ragged 
ulceration  with  fungating  edges.  In  the  patient  of  Sept. 
Gibbon,  the  tumor  was  the  size  of  two  fists,  arising  by  an 
extended  base  from  the  anterior  surface.  At  the  posterior 
surface,  the  mucous  membrane  was  studded  with  numer- 
ous wart-like  medullary  growths.  Section  of  growth  pre- 
sented white,  pulpy,  pear-like  appearance,  except  in  the 
centre,  which  was  softened  and  broken  down,  containing 
buff-colored,  offensive  pus. 


J  .  TUMORS    OF    THE    BLADDER. 

Villous  cancer  is  a  form  of  epithelioma.  It  is  a  soft, 
spongy  mass,  projecting  from  the  wall  of  the  bladder,  and 
havino-  on  its  svirface  those  peculiar  vascular  processes 
from  which  it  derives  its  name.  It  differs  from  the  benign 
villous  growth,  mainl_y  in  that  the  latter  is  limited  to  the 
mucous  membrane,  and  its  villous  processes  have  but  a 
scantv  epithelial  covering,  through  which  the  capillary  loop 
within  can  be  distinctly  seen,  while  the  villous  cancer  has 
a  deeper  origin  in  the  connective  tissue,  constituting  a 
thickening  of  the  vesical  walls,  or  forming  a  tumor  which 
may  be  recognized  by  external  palpation.  Its  villi  have 
an  abundant  epithelial  investment,  by  which  the  interior 
of  its  structure  is  obscured  or  rendered  invisible  ;  but  most 
prominentl}"  is  its  malignant  nature  manifest  by  the  infil- 
tration of  its  base  and  villi  with  closeh-packed  epithelial 
cells  (see  Plate  viii.). 

Scirrhus  of  the  bladder  is  undoubtedly  rare.  Bastian 
and  Butlin  have  each  reported  a  case  which  they  regard 
as  typical  of  the  disease.  In  the  first  patient,  the  base 
and  anterior  wall  of  the  bladder  were  thickened  and  infil- 
filtrated  with  cancerous  material.  The  mucous  mem- 
brane was  entire  and  healthy,  though  raised,  and  irregular 
on  the  surface.  There  was  no  distinct  tumor.  In  the 
patient  of  Butlin,  there  was  a  uniform  infiltration  -of  all 
the  coats  of  the  bladder ;  its  capacity  was  so  much  dimin- 
ished that  it  could  onl}'  hold  an  ounce  of  fluid ;  and  owing 
to  the  stiffness  of  its  walls  did  not  admit  either  of  contrac- 
tion or  dilatation.  Its  mucous  membrane  was  corrugated 
and  inflamed.  The  bladder  was  very  adherent  to  sur- 
rounding parts  by  extension  of  the  disease,  and  could  only 
be  removed  by  free  use  of  the  knife.  It  had  eaten  deeply 
into  the  pelvic  bone,  on  the  right  side,  the  body  of  which 
was,  in  great  part,  destroyed.  Microscopic  examination 
showed  that  the  cancer  was  not  only  of  the  hard  variety, 
but  quite  deserved  the  name  of  scirrhus.  The  cells  were 
generally  of  smaller  size,  with  much  smaller  nuclei  than 


TUMORS    OF    THE    BLADDER. 


15 


usually  occur  in  the  medullary  cancer  of  the  bladder. 
The  stroma  consisted  for  the  most  part  of  very  firm  and 
abundant  fibrous  tissue.  In  both  the  above  cases,  secon- 
dary deposits  were  found  in  the  abdominal  glands,  liver, 
kidneys,  beneath  the  peritoneum,  and  beneath  the  parietal 
pleura. 

Cancer  of  the  bladder  may  be  primary  or  secondary  ; 
that  is,  the  malignant  growth  may  originate  directly  in  the 
tissues  of  the  bladder,  or  this  viscus  may  become  involved 
by  extension  of  the  disease  from,  neighboring  parts. 

As  a  primary  affection,  cancer  of  the  bladder  is  not  com- 
mon. As  secondary  to  the  disease  in  the  female  sexual 
organs,  prostate,  rectum,  etc.,  literature  affords  an  ample 
number  of  cases.  Out  of  4,777  autopsies  (3,043  male,  and 
i,734female)  recorded  at  the  Pathological  Institute  of  Ber- 
lin, from  1859  to  1868,  Max  Hilborn  found  37  cases  of  cancel", 
of  which  33  occurred  in  women,  and  four  in  men.  Out  of 
the  37  cases,  the  disease  was  secondary  in  30,  primary  in 
7.  In  29  of  the  secondary  cases,  the  extension  occurred 
from  the  uterus,  and  in  one  from  the  rectum.  Of  the 
7  primar}^  cases,  4  occurred  in  women,  3  in  men.  As 
among  the  4,777  subjects,  3,043  were  male,  and  1,734  female, 
the  vesical  cancer  occurred  15  times  oftener  in  women 
than  in  men ;  but  the  percentage  of  primary  cancer  was 
i2'/o  against  75/^  in  men. 

According  to  Winckel,  out  of  2,505  autopsies  of  women 
made  at  the  Dresden  Krankenhaus,  there  were  73  vesical 
cancers.  That  is  a  percentage  of  nearlj^  30  against  20 
recorded  in  Berlin. 

Secondary  cancer  is  infinitely  more  common  than  pri- 
mary. It  is  much  more  common  in  women  than  in  men, 
while  primary  cancer  seems  to  be  more  frequent  in  men 
than  in  women. 

Secondary  cancer  of  the  bladder  in  women  is  almost 
without  exception  an  extension  of  the  disease  from  its 
favorite  seat,  the  pars  cervicalis  uteri.     The  frequency  of 


J 5  TUMORS   OF    THE   BLADDER. 

cancer  of  the  uterus  and  the  portio  vaginalis  uteri  with 
its  tendency  to  spread  towards  the  bladder  accounts  for 
the  frequency  of  vesical  cancer  in  the  female. 

In  men,  as  a  secondary  disease,  cancer  is  generally  an 
extension  from  the  prostate,  rectum,  or  vesiculse  semi- 
nales. 

That  epithelioma  is  the  most  common  variety  of  cancer 
found  in  the  bladder  must  be  inferred  from  its  greatest 
frequency  in  women  as  a  secondaiw  affection  from  the 
uterus,  for  which  organ  epithelioma  has  so  great  a  predi- 
lection. But  this  is  true,  not  only  for  the  secondary  cases, 
but  also  for  the  primar}'.  Indeed,  it  is  exceptional  to  find 
other  than  epithelial  or  villous  cancers  originating  in  the 
Avails  of  the  bladder.  As  has  been  said,  they  occur  more 
frequently  in  men  than  in  women.  In  at  least  sixteen  of 
our  cases  the  primary  origin  of  the  cancer  in  the  bladder 
cannot  be  doubted,  though  I  have  been  circumspect  in  my 
selection  of  them.  Of  these,  ten  are  male  and  six  female. 
It  is  not  always  easy  to  determine  whether  a  given  tumor 
is  primarv  or  secondarj'  to  the  bladder,  and  this  question 
is  too  often  disposed  of  at  first  glance.  From  our  number 
of  cases  collected,  I  have  excluded  several  announced  as 
"  primary  cancer,"  which,  on  account  of  extensive  involve- 
ment of  neighboring  parts  could  not  be  accepted  as  such 
without  much  doubt.  Thus,  in  one  instance  of  reported 
primary  vesical  cancer,  it  is  said  "the  neoplasm  involved 
the  abdominal parictcs,  rectum,  and  several  coils  of  small  iji- 
testine,  thozigh  it  did  not  implicate  either  the  vesical  or  intesti- 
nal mucous  m£mbra7ier  I  should  think  it  almost  impossible 
to  say  where  such  vast  disease  had  its  origin.  i\gain,  that 
the  bladder  is  quite  as  subject  to  invasion  by  metastasis 
as  other  organs  of  the  body  is  a  circumstance  apparently 
not  kept  in  vicAv.  In  some  of  our  cases,  the  disease  in  the 
bladder  was  undoubtedly  recent,  and  insignificant  as  com- 
pared vv'ith  the  cancerous  development  elsewhere.  Thus 
we  have  an  instance  of  "  two  or  three  small  masses  of  en- 


TUMORS   OF    THE   BLADDER.  \y 

cephaloid  in  the  bladder,  while  no  part  of  the  left  kidney 
could  be  found,  and  a  mass  of  encephaloid  occupied  its 
place."  If  the  extent  of  disease  is  any  index,  in  this  case 
it  is  quite  possible  that  the  kidney  and  not  the  bladder  (as 
stated)  was  the  original  seat  of  the  disease.  But,  on  the 
other  hand,  we  may  err  in  the  opposite  direction,  and  re- 
gard all  cases  secondary  in  which  the  rectum,  prostate,  or 
vesiculce  seminales  happen  to  be  continuously  affected  with 
the  bladder.  In  other  words,  I  would  say,  that  primary 
cancer  of  the  bladder  may  be  more  common  than  is  gen- 
erally supposed,  and  that  the  disease,  instead  of  originating 
in  the  vagina,  uterus,  rectum,  or  prostate,  these  parts  are 
secondarily  affected  by  extension  of  the  disease  from  the 
bladder.  There  is  nothing  irrational  in  the  acceptance  of 
these  premises,  and  some  of  our  cases  make  such  a  conclu- 
sion inevitable.  When  the  disease  is  said  to  have  "  appa- 
rently involved  the  prostate,"  or  to  have  "  extended  up  to 
it,"  or  "  within  half  an  inch  of  it,"  or  when  the  tumor  is 
said  to  have  attained  considerable  size,  become  ulcerated, 
etc.,  within  the  viscus,  while,  without,  it  had  simpl}'  created 
adhesions  with  the  outer  surface  of  the  uterus,  rectum, 
colon,  or  small  intestine,  the  natural  conclusion  is,  that  the 
disease,  originating  in  the  bladder,  would  have  involved 
these  parts  had  not  death  arrested  its  progress.  In  not 
a  few  cases  were  such  adhesions  found  between  the  blad- 
der, uterus,  vagina,  intestines,  abdominal  walls,  and  some- 
times ulcerative  communication  existed  between  these 
organs.  In  one  case  such  a  communication  existed 
between  the  base  of  the  bladder  and  uterus,  the  latter 
serving  as  an  outlet  for  the  urine,  which  was  constantly 
dribbling  away  during  life.  In  another,  fasces  were  passed 
with  the  urine. 

Again,  the  cancer  may  develop  simultaneously  at  several 
points,  as  in  the  case  of  Hutchinson,  in  which  were  numer- 
ous masses  of  medullary  C3.ncQV  perfectly  distinct  from  each 
other  in  the  submucous  tissue  of  the  vagina,  rectum,  and-  blad- 


1 8  TUMORS    OF    THE    BLADDER. 

dcr.     I  mention  these  facts  as  showing  that  it  is  often  diffi- 
cult to  determine  the  real  origin  of  cancer  of  the  bladder. 

The  most  frequent  locality  of  cancer  appears  to  be  on  the 
posterior  wall,  the  next  most  common  seat  is  the  trigone. 
Sometim.es  the  attachment  is  simply  given  as  "on  the 
body,"  rarely  is  the  vertex  mentioned  as  the  seat  of  the 
disease. 

With  reference  to  age,  cancer  of  the  bladder  would 
appear  to  occur  in  greatest  frequency  between  the  ages  of 
forty  and  fifty,  fifty  and  sixty,  thirty  and  forty,  sixty  and 
seventy-five,  and  twenty  and  thirty.  Our  oldest  patient 
was  seventy-five  years  old.  Billroth  had  a  case  of  m3"0- 
carcinoma  in  a  bo}^  aged  twelve,  but  cancer  rarely  occurs 
before  the  twentieth  year.  A  unique  case  is  reported  by 
Smyth  of  medullary  cancer  in  a  child  four  years  old, 
which  is  in  several  respects  interesting.  The  symptoms 
were  frequent  micturition  and  hcematuria,  but  there  was  no 
•complaint  Avhatever  of  pain  or  tenderness  in  the  abdomen. 
April  loth,  there  was  sudden  discharge  of  arterial  blood, 
followed  by  purulent  matter,  the  result,  no  doubt,  of  the 
giving  way  of  an  abscess.  For  some  days  there  was  a  free 
discharge  of  muco-purulent  matter  tinged  Avith  blood. 
May  29th,  after  a  very  restless  night,  she  uttered  a  most 
piercing  shriek,  followed  by  syncope,  and  she  died  in  three 
liours.  Abdomen  only  part  examined,  bladder  much  hy- 
pertrophied,  a  cyst  of  an  abscess  was  discovered  on 
the  left,  inferiorly,  upon  the  edges  of  which  w^ere 
phosphatic  depositions.  Interior  of  viscus  was  filled  with 
soft,  broken-down,  medullary  matter,  resembling,  in  fact, 
pounded  cerebral  substance.  Under  microscope,  cancer 
cells  were  discernible.    Kidneys  were  secondarily  affected. 

Before  passing  to  the  consideration  of  other  varieties  of 
tumor,  I  will  here  record  two  cases  of  primary  cancer 
which  have  come  under  my  observation,  and  which  pre- 
sent features  of  much  interest.  The  first  is  that  of  L.  F., 
German,  aged  44;  shoemaker.     Never  had  any   serious 


TUMORS   OF   THE   BLADDER. 


19 


illness ;    has   always  enjoyed  good  health,   when  at  the 
age  of  twenty-three,  he  found,  on  waking  one  morning,  a 
considerable  quantity  of  clotted  blood  in  his  bed  ;  had  no 
pain.     Four  years  afterward  (when  twenty-seven),  noticed 
for  the  first  time  blood  in  his  urine.     It  appeared  without 
any  assignable  cause,  and  remained  only  a  day.     Ten  years 
afterward  (when  thirty-seven),  noticed  bjood  in  his  urine 
the  second  time,  which  continued  some  days  and  disap- 
peared upon  taking  medicine.     Ever  since,  however,  blood 
has  appeared  in  the  urine  at  intervals,  with  some  pain  in 
micturition.     He  remained  in  this  condition  up  to  August, 
1879,  when  blood  appeared  constantly  in  the  urine,  some- 
times in  small  and  sometimes  in  large  quantities  ;   clots 
also  now  appeared  for  the   first  time  ;    micturition  also 
became  frequent  and  painful.     Admitted  to  Charity  Hos- 
pital December  3d,  1879.     Anaemic  and  weak,  complains  of 
palpitation  of  the  heart  on  least  exertion.     Has  pain  in 
his  right  lower  extremity  ;  micturition  very  frequent  and 
painful,    thinks    he    could   pass    a    pailful  of    water,  but 
only  a  few  drops  come  away  at  a  time.     The  pain  in  mic- 
turition is  at  the  neck  of  the  bladder  and  at  the  glans  penis. 
Almost  every  time  he  urinates  he  finds  clotted  blood  in 
the   urine.     Has  noticed  that,  while  passing  water,  the 
stream  will  suddenly  become  arrested  and  start  again  in  a 
moment,  preceded  by  a  clot  of  blood.     Has  pain  behind 
the  pubes.     Urine  sp.  gr.  1.012  neutral,   dark-red,  holds 
about  forty  per  cent  of  albumen  and  contains  a  thick  de- 
posit of  pus,  blood-corpuscles,  and  epithelium.     A  stric- 
ture was  found,  five  and  three-quarter  inches  from  meatus, 
admitting  16  A.     December  loth,  thinks  he  feels  better ; 
pain  in  hypogastrium  and  thigh  gone.     December  13th, 
during  the  night,  was  unable  to  pass  water;  the  bladder 
became  distended  and  painful ;  in  the  morning,  a  large  clot 
came  away,  after  that  the  urine  again  flowed  freely.     Janu- 
ary 6th,  always  complains  of  more  or  less  pain  in  region  of 
right  buttock  and  thigh.     Passed  a  large  clot  of  blood  this 


^Q  TUMORS   OF   THE   BLADDER. 

morning,  previous  to  which  had  much  pain  over  hypogas- 
trium.  Transferred  to  Ward  6.  In  this  ward  he  was  in 
bed  most  of  the  time,  and  was  given  ergot,  gallic  acid, 
iron,  etc.,  but  his  condition  remained  unimproved.  The 
patient  was  seen  by  me  for  the  first  time  in  March,  when 
bv  palpation  and  catheterization  1  distinctly  recognized  a 
tumor  at  the  trigone,  involving  especially  the  right  side 
of  the  bladder.  Three  days  previous  to  death,  patient 
became  semi-comatose,  emitted  an  offensive  urinous  odor, 
and  fibrillary  contractions  of  the  muscles  of  the  arms  and 
neck  were  observed.  Rectal  alimentation  was  necessary, 
patient's  jaws  resisting  all  efforts  to  open  them.  Death 
ensued  March  28th,  1880,  at  6  p.m. 

Autopsy  by  Dr.  Holmes. — Onl}^  bladder,  ureters,  and 
kidneys  were  examined.  Bladder  was  contracted,  and 
contained  about  3  ij.  of  urine.  Projecting  from  the  tri- 
o-one and  right  wall  of  the  bladder  is  a  mass,  circular  in 
form,  about  four  and  one-half  inches  in  diameter,  consider- 
ably elevated,  with  convex  lobulated  surface,  presenting 
numerous  sulci  or  depressions,  and  covered  with  shreds  of 
tissue.  The  entire  mass  is  rather  pale,  and  in  the  contracted 
condition  of  the  bladder  almost  completely  fills  its  cavity, 
being  about  the  size  of  the  fist.  Mucous  membrane  else- 
where is  thickened  and  pale.  See  Plate  v.  Ureters  :  left 
normal,  right  moderately  dilated  and  thickened.  Kid- 
neys :  right  is  smaller  than  normal ;  external  surface  is  of 
deep  color  and  covered  with  blackish-red  ecch3'-motic 
spots.  On  section,  find  the  kidney  in  condition  of  hydro- 
nephrosis. What  remains  of  cortical  portion — a  very  nar- 
row rim — is  very  firm,  pale-red,  and  shows  the  same  ecchy- 
motic  condition  as  the  external  surface.  The  lining 
membrane  of  the  dilated  pelvis  and  calyces  is  very  pale. 
On  cutting  through  the  cortical  portion  at  several  points, 
small  masses  of  secondary  cancerous  deposit  are  found ; 
they  are  about  the  size  of  a  split  pea.  Left  kidney  is  swoL 
len,   deep-red  color,  and  shows  hemorrhages  on  surface 


TUMORS    OF    THE    BLADDER. 


21 


Plate  V. 


Primary  Encephaloid  Cancer. 
Original  drawing  from  one  of  the  author's  cases. 


22 


TUiMORS    OF    THE    BLADDER. 


Plate  VI. 


X  400. 
Microscopic  appearance  of  encepnaloid  tumor  (PI.  V.). 


TUMORS    OF    THE    BLADDER.  2^ 

and  on  section.  The  cortical  substance  is  markedly  swol- 
len ;  Malpighian  bodies  prominent  and  deep-red.  The 
P3^ramids,  deeply  congested,  columns  of  tubules  can  be 
traced  almost  everywhere ;  appear  broader  than  normal, 
and  have  gra3'ish-yellow  color. 

Microscopic  appearances. — The  tumor  was  examined  by 
Dr.  Carl  Heitzmann,  who  found  it  to  consist  of  delicate 
fibrous  connective  tissue,  inclosing  large  and  numerous 
alveoli  (Plate  vi..  A),  which  latter  are  filled  with  large  and 
irregular  epithelia.  The  connective  tissue  framework  is 
crowded  with  globular,  mostly  homogeneous  corpuscles, 
at  some  places  to  such  an  extent  that  the  fibrous  structure 
of  the  connective  tissue  is  obscured  (B).  The  epithelia 
within  the  alveoli  are  coarsely  granular,  supplied  with 
large  nuclei,  either  single  or  multiple.  Diagnosis  :  medul- 
lary cancer. 

The  second  patient  was  that  of  a  lady,  aged  sixty -nine. 
Some  time  during  the  month  of  August,  1880,  while  in  the 
country,  and  lying  in  bed  one  afternoon  by  the  open  win- 
dow, a  thunder-storm  came  on,  and  during  a  vivid  flash  of 
lightning,  felt,  as  she  said,  "a  shock  of  electricity,  which 
passed  through  me  from  head  to  foot."  Soon  after  she 
got  up,  passed  water,  and  saw  that  it  contained  blood.  The 
urine  continued  to  be  tinged  with  blood,  though  slightly, 
for  about  two  weeks,  during  which  time  she  kept  her  bed, 
according  to  her  physician's  advice,  but  she  had  no  pain 
or  inconvenience  of  any  kind.  After  two  weeks,  she  left 
her  bed,  and  the  hematuria  disappeared  spontaneously. 
From  this  time  to  November  nth,  there  had  been  no  re- 
currence of  hemorrhage,  but  on  this  day  the  urine  again 
became  tinged  with  blood.  November  12th,  urine  free 
from  blood,  color  pale,  quite  clear ;  no  appearance  of  any 
abnormality  to  naked  eye  ;  no  albumen  with  heat  and  acid. 
November  20th,  sharp  hemorrhage  commenced  to-day ; 
urine  contains  large  clots ;  is  obliged  to  empty  bladder 
every  twenty  minutes  to  one  and  a  half  hours,  with  con- 


24  TUMORS    OF    THE    BLADDER. 

siderable  bearing-down  pains,  owing  to  the  presence  of 
clots  in  the  bladder.  Gallic  acid,  ergot,  turpentine,  iron 
chloride,  aromatic  sulphuric  acid  were  administered  freely 
and  m  large  doses,  but  apparently  without  any  effect.  The 
hemorrhage  continued,  and  the  patient  became  thoroughly 
aneemic  and  much  exhausted.  December  9th,  extreme 
nausea  and  irritability  of  stomach ;  refuses  all  medicine 
and  nourishment :  pulse  rapid  and  feeble,  prostration  ex- 
treme ;  stniiulants  and  nourishment  administered  by  rec- 
tum. For  several  da^-s  little  hope  was  entertained  of  her 
recovery.  She  rallied,  however,  m  a  most  marvellous 
manner:  the  blood  gradually  disappeared  from  the  urine 
without  any  remedies ;  stomach  returned  to  its  normal 
condition  ,  appetite  improved  rapidly,  and  the  good  old 
lad}^  became  once  more  herself.  December  21st,  appetite 
good ;  cheerful,  and  hopeful  for  the  future  ;  urine  pale, 
feebly  alkaline ;  no  blood ;  very  little  free  pus,  but  quite 
large  flakes  of  mucoid  material,  impregnated  with  triple 
phosphates,  exist  in  the  water,  and  there  is  alwa3''S  the 
same  slimy  material  deposited  in  the  chamber  or  in  the 
bottle  of  urine  brought  for  examination.  She  now  com- 
plains of  frequency  of  micturition,  and  a  severe  burning  at 
the  vesical  neck  at  the  completion  of  the  act.  This  is  the 
first  time  she  has  complained  of  any  pain  other  than  the 
bearing  down  hitherto  experienced,  consequent  upon  the 
expulsion  of  clots.  January  i6th,  1881,  has  continued 
about  the  same  since  last  report.  Sometimes  there  is  con- 
siderable frequency  of  micturition,  with  pain  ;  while,  again, 
she  is  capable  of  holding  water  several  hours,  and  there 
is  absolute  freedom  from  pain  during  micturition.  Gelat- 
inous particles  still  float  in  the  urine,  and  slimv  deposit 
continues,  but  not  nearl}^  so  much  as  before.  There  has 
also  been  an  occasional  reappearance  of  the  hsematuria,  but 
not  for  some  eight  or  ten  da3^s  ;  is  to  sit  up  a  few  hours 
dail}'.  January  21st,  had  considerable  pain  in  region  of 
left   kidnev,   extending    downward    over  the    left   side  of 


TUMORS   OF    THE   BLADDER. 


25 


bladder.  Applied  turpentine  stupes,  which  gave  partial 
relief.  Nevertheless,  she  continued  to  complain  of  con- 
siderable pain,  especiall}^  over  left  side  of  bladder,  and 
extending  down  the  thigh,  for  some  ten  days  afterward. 
At  times  the  pain  would  be  slight,  and  again  quite  sharp. 
There  had  been  an  occasional  recurrence  of  the  hsema- 
turia,  blood  appearing,  perhaps,  at  one  micturition,  while 
at  the  next  the  urine  would  be  perfectly  clear.  February 
loth,  has  been  sitting  up  a  few  hours  almost  daily  since 
January  i6th.  Has  taken  iron,  quinine,  etc.,  but  during 
the  past  five  or  six  da3-s  there  has  been  more  or  less  blood 
in  the  urine  nearly  all  the  time.  Is  very  nervous,  and  ap- 
petite is  again  failing  rapidly.  Again  proposed  a  digital 
exploration  of  the  interior  of  the  bladder,  with  the  view 
of  possibly  effecting  the  removal  of  the  tumor.  Hoping, 
however,  to  become  stronger  in  a  few  days,  she  requested 
that  the  examination  should  be  again  deferred.  February 
13th,  hemorrhage  agam  profuse  ;  passes  water  every  tAvent}" 
or  thirty  minutes  ;  considerable  bearing-down  pains  from 
the  accumulation  of  clots  in  the  bladder ;  excessive  nau- 
sea; unable  to  retain  an}- thing  on  stomach,  excepting  very 
small  quantity  of  champagne.  Nutritive  and  stimulating 
enemata  were  given,  but  she  sank  rapidly,  and  died  at 
8  A.M.,  February  15th,  1881. 

■Autopsy  made  Feb.  17th.  Only  bladder  and  left  kidney 
examined.  Bladder  found  distended  with  soft  clots,  its 
walls  much  atonied,  being  extremely  thin  at  the  vertex. 
Mucous  m.embrane  vascular  throughout.  A  tumor  was 
found,  situated  directly  over  the  orifice  of  the  left  ureter. 
It  was  about  four  and  a  half  inches  in  diameter,  and  pro- 
jected from  the  surface  about  an  inch.  It  was  attached 
by  a  broad  base,  nearly  equal  in  diameter  with  the  rest  of 
the  tumor,  and  its  surface  presented  the  shaggy  appear- 
ance characteristic  of  villous  growths  (see  Plate  vii.).  On 
the  opposite  side,  the  coats  of  the  bladder  are  also  infil- 
trated with  cancerous  material.     Left  ureter  dilated  and 


26 


TUMORS   OF    THE    BLADDER. 


Plate  VII. 


Primary  Villous  Cancer. 
Original  drawing  from  one  of  the  author's  cases. 


TUMORS  OF   THE   BLADDER. 


27 


Plate  VIII. 


X  200. 


Microscopic  appearance  of  villous  cancer  (PI.  VII.). 


28  TUMORS   OF    THE   BLADDER.  fc 

hypertrophied,  especially  at  entrance  into  bladder.  Left 
kidney  small,  pelvis  dilated,  pyelitis  and  C3^stic  change 
commencing  in  the  organ  itself.  Right  kidney  was  acci- 
dentally returned  into  abdomen  without  examination.  Ya- 
gina,  uterus,  rectum,  and  neighboring  organs  were  entirely 
free  from  disease.  Microscopic  examination  by  Dr.  C. 
Heitzmann  found  the  tumor  to  be  composed  of  a  rather 
coarse,  fibrous  connective  tissue,  highly  vascularized,  and 
sprouting  on  the  surface  into  numerous  bud-like  elon- 
gations (Plate  viii..  A),  varying  in  length  from  o.oi  mm. 
to  3-4  mm.  Most  of  the  buds  are  covered  with  a  single, 
irregular,  columnar  epithelium ;  the  elongations  them- 
selves, as  well  as  the  subjacent  connective  tissue,  is 
infiltrated  with  numerous,  partly  globular,  partly  oblong 
corpuscles  (B).  Within  the  connective  tissue  are  seen 
alveoli  of  small  size  (nests,  C),  containing  a  number  of 
epithelia:  the  latter  are  mostly  provided  with  only  one 
nucleus.     Diagnosis,  villous  cancer. 

MYOMATA. 

Myomata  occur  very  rarely  in  the  bladder.  The  follow- 
ing are,  no  doubt,  the  only  instances  of  this  new-formation 
that  can  be  found  in  literature, 

Myo-carcinovia. — Virchow,  in  his  work  on  "  Geschwiilste," 
makes  allusion  to  this  form  of  tumor  in  the  description  of 
a  myo-carcinoma,  which  was  situated  on  the  posterior  wall 
of  the  bladder,  towards  the  point  of  the  trigone.  The 
greater  part  of  the  tumor  was  apparent  in  the  submucous 
tissue ;  but  its  deeper  portion  was  continuous  with  the 
muscular  coat.  Microscopic  examination  showed  a  great 
resemblance  to  a  genuine  myoma.  The  portion  lying  in 
the  submucous  tissue  showed  entirely  the  structure  of 
scirrhus. 

Faye  mentions  a  case  of  supposed  fibro-myoma.  The 
tumor  was  situated  between  the  anterior  wall  of  the  blad- 
der  and    the    fascia    transversalis.      It   was    eisrhteen   to 


TUMORS    OF    THE    BLADDER.  20 

nineteen  centimetres  long,  sixteen  to  seventeen  broad,  and 
ten  centimetres  thick.  It  was  so  intimately  connected 
with  the  vesical  wall,  that  it  seemed  to  have  its  origin 
therein,  though  Faye  says  it  is  possible  that  it  originated  in 
the  subperitoneal  connective  tissue. 

Myosarcoma  and  carchioma. — A  patient  of  Billroth,  aged 
twelve  years,  was  troubled  for  ten  months  with  frequent 
and  painful  micturition.  The  urine  remained  feebly  acid, 
slightly  cloudy,  but  contained  nothing  characteristic  on 
microscopic  examination,  except  a  moderate  quantit}^  of 
pus-corpuscles,  and  a  few  cells  of  bladder  epithelium.  A 
tumor  was  felt  through  the  abdominal  walls,  about  the 
size  of  the  fist.  It  could  also  be  felt  through  the  rectum. 
The  tumor,  which  was  successfully  removed  by  supra- 
pubic incision,  had  its  origin  from  the  posterior  Avail,  and 
extended  towards  the  top  of  the  bladder.  It  was  eight 
centimetres  long,  four  broad,  and  eighteen  in  circumfer- 
ence in  one  direction,  and  thirteen  in  another :  its  base  was 
seven  centimetres.  Its  surface  was  nodulated  ;  it  was 
smooth  and  not  ulcerated.  It  took  its  origin  distinctly 
from  the  muscular  coat,  and  was,  therefore,  a  myoma,  but 
the  tumor  had  undergone  a  sarcomatous,  and,  in  places,  a 
carcinomatous  transformation.  (Plate  ix.,  shows  the  rela- 
tive size,  form,  seat,  etc.,  of  tumor.) 

The  next  three  cases  are  instances  of  pure  myoma.  The 
first  is  Volkmann's  patient,  aged  fifty-four.  For  six  months 
has  suffered  from  tenesmus,  strangury,  sharp  pains  in 
glans  penis  during  micturition,  and  hemorrhage,  with  pro- 
duction of  large  clots.  Urine  contains  neither  mucus  nor 
pus-corpuscles.  Bimanual  examination  reveals  a  hard,  elastic, 
and  easily  movable  tumor  in  the  upper  part  of  the  bladder, 
about  the  size  of  a  hen's  ^%%.  The  tumor  was  unsuccess- 
fully removed  by  supra-pubic  incision.  It  was  8.25  cm. 
long,  6.5  broad,  21.5  cm.  in  longitudinal,  and  17.75  i^i 
transverse  circumference.  The  pedicle  was  half  an  inch 
long,  and  of  the  thickness  of  the  little  finger,  and  attached 


30 


TUMORS   OF   THE  BLADDER. 


Plate  IX. 


:;^\\ 


Billroth's  Myo-sarcoma  and  Carcinoma. — Arck,  f.  Klin.  Chir.,  Bd.  i8. 


TUMORS   OF   THE   BLADDER. 


31 


Plate  X. 


Yolkmann's  Myoma. — Arch,  f,  Klin.  C/iir.,  Bd.  19. 


,^  TUMORS   OF    THE   BLADDER. 

to  the  vertex  anteriorly,  and  a  little  to  the  left.  The 
tumor  was  of  the  size  and  form  represented  at  Plate  x., 
and  microscopic  examination  found  it  to  be  a  pure 
myoma.  Dr.  H.  Chiarri,  prosector  to  the  Rudolfs-Spital, 
Vienna,  found,  post-mortem,  two  cases  of  pure  myoma, 
which  are  described  by  Belfield,  in  the  Wien.  Med. 
Wochschr.  The  first  was  a  female,  aged  fifty,  who  died  of 
bilateral  pleuro-pneumonia.  On  the  outer  surface  of  the 
contracted  bladder,  and  on  the  left  side  of  its  base  was  a 
firm,  sharply-defined  tumor  the  size  of  a  nut,  imbedded  in 
the  loose,  perivesical  areolar  tissue.  It  had  the  shape  of 
an  egg  with  its  longitudinal  axis  directed  vertically,  and 
had  a  smooth  surface.  It  was  two  centimetres  long,  one 
centimetre  thick,  and  two  centimetres  broad.  On  remov- 
ing the  surrounding  adipose  tissue,  there  appeared  four 
thm  cords  (Strange),  which  could  be  traced  from  the  under 
surface  of  the  tumor  into  the  muscular  coat  of  the  bladder, 
and  consisted  partly  of  sm.ooth  muscular  fibres,  and  in 
part  of  blood-vessels.  These  cords  led  through  an  elhpti- 
cal  gap,  fifteen  millimetres  long  and  eight  millimetres  wide, 
in  the  external  muscular  layer  into  the  inner  layers  of  the 
muscular  coat,  which  made  it  evident  that  the  tumor  had 
its  origin  therein.  It  had  no  connection  with  the  uterus, 
which  also  had  a  myoma  the  size  of  a  bean  on  the  anterior 
surface  of  its  fundus  beneath  the  peritoneum. 

The  second  subject  was  a  male  aged  seventy-four,  who 
died  of  pneumonia.  There  was  considerable  enlargement 
of  the  middle  lobe  of  the  prostate,  which  was  otherwise 
only  slightly  tumefied.  The  muscular  coat  of  the  bladder 
was  considerably  hypertrophied,  and  its  mucous  mem- 
brane was  in  a  condition  of  catarrhal  inflammation.  The 
left  ureter  was  greatly  dilated,  and  the  corresponding 
kidney  hydronephrotic  ;  the  right  kidney  was  not  changed. 
The  cause  for  the  dilatation  of  the  left  kidney  and  the 
hydronephrosis  was  the  existence  of  a  small  tumor  covered 
with   mucous   membrane,   just   below   the   orifice  of  the 


TUMORS    OF   THE   BLADDER.  33 

left  ureter  which  it  compressed.  The  tumor  was  tuber- 
ous, and  could  be  enucleated  (ausschalbar).  It  had  a 
diameter  of  seven  millimetres.  Both  these  tumors  had 
their  origin,  undoubtedly,  from  the  muscular  tissue  of  the 
bladder.  They  were  carefully  examined  under  the  micro- 
scope and  with  the  proper  reagents,  and  were  found  to  be 
composed  of  organic  muscular  fibres,  with  a  little  connec- 
tive tissue  and  blood-vessels.  It  is  interesting  to  note  the 
coincidence  of  a  myoma  of  the  uterus  in  one  case,  and  the 
hypertrophied  condition  of  the  prostate  in  the  other. 

SARCOMATA. 

Sarcoma  is  one  of  the  rarest  diseases  of  the  bladder ; 
there  are  but  few  authentic  cases  on  record.  The  first  of 
these  was  recorded  by  Senftleben  in  i860.  A  woman,  aged 
twenty-nine,  was  troubled  with  irritable  bladder,  inconti- 
nence, and  hsematuria.  She  had  noticed  that  in  straining  at 
stool  a  reddish  fleshy  mass  appeared  at  the  meatus,  which 
she  herself  cut  away  several  times  without  pain.  When  she 
applied  for  treatment,  the  hypogastrium  was  tender  on 
pressure,  an  inguinal  gland  on  the  right  side  was  as  large 
as  a  walnut.  The  urethra  had  been  dilated  by  the  tumor 
sufficiently  to  admit  the  index  finger.  Examination  re- 
vealed a  soft  elastic  tumor  attached  by  a  broad  pedicle  to 
the  posterior  and  upper  part  of  the  bladder.  A  piece  of 
the  tumor  was  torn  away  and  examined  microscopically  by 
Billroth,  who  declared  it  to  be  a  spindle-celled  sarcoma. 
The  greater  part  of  this  mass  was  afterward  removed,  but 
the  patient  died  on  the  fourth  day  from  purulent  perito- 
nitis, the  bladder  having  been  perforated  during  the  oper- 
ation. Autopsy  revealed  another  tumor  which  had  its 
origin  from  the  intermuscular  connective  tissue. 

Marchand s  patient,  a  female,  aged  fifty-seven,  had  suf- 
fered for  two  years  with  vesical  catarrh  ;  there  had  been 
considerable  strangury  and  tenesmus  vesicas,  and  every 
half-hour  a  few  drops  of  thick,  highly  foetid  urine,  contain- 
3 


34  TUMORS   OF    THE    BLADDER. 

ing  shreds  of  tissue,  were  passed.  TJiere  was  never  any 
Juematiiria.  After  bloodless  dilatation  of  the  urethra  the 
finger  discovered  a  tumor  on  the  lower  and  posterior 
wall  of  the  bladder.  It  was  found  that  the  tumor  and  the 
vesical  wall  were  in  firm  connection  with  the  uterus,  and 
for  that  reason  no  attempt  was  made  at  extirpation.  Pa- 
tient died  of  exhaustion.  P.  M.  Posterior  wall  and  trigone 
of  the  bladder  was  occupied  by  a  tumor  the  size  of  an 
apple  (Borsdorfer  Apfel).  The  principal  mass  was  situated 
in  the  right  half  of  the  bladder,  while  in  the  centre  and 
towards  the  left  the  greater  portion  of  the  tumor  was 
broken  down  and  had  a  deep  ragged  ulcerated  sulcus. 
Tumor  occupied  pretty  much  the  entire  thickness  of  the 
vesical  wall,  had  its  origin  from  the  intermuscular  connec- 
tive tissue,  and  microscopically  presented  the  structure  of 
a  round-celled  sarcoma.  The  anterior  wall  of  the  vagina 
and  of  the  uterus,  which  v/ere  connected  to  the  bladder  by 
a  firm  structure,  were  entirely  unaffected.  The  rest  of 
the  bladder  was  scarcely  thickened.  There  were  meta- 
static deposits  in  the  lung,  hydronephrosis,  pyelonephri- 
tis, etc. 

Heath  reports  the  case  of  a  female  aged  thirty-nine. 
Passed  little  blood  zvith  urine  at  various  times  for  several  years, 
complained  of  constant  desire  to  micturate,  but  in  doing  so  ex- 
perienced no  pain  or  difficulty,  although  evidences  of  inflamma- 
tion were  most  marked.  The  urethra  was  dilated  and  the 
right  side  of  the  bladder  was  found  to  be  occupied  by  a 
villous  growth,  situated  on  a  hardened  base.  Some  of  the 
■growth  was  torn  away.  Patient  died  from  general  exhaus- 
tion. Inner  surface  of  bladder  was  found  to  be  covered 
with  villous  processes  coated  with  phosphatic  deposits. 
Several  growths  external  to  the  bladder  were  found. 
Microscope  showed  new-growths  to  be  medium-sized, 
round-celled  sarcomata,  and  the  villous  growth  in  the 
bladder  rested  on  a  hardened  base  made  up  of  round  cells 
rather  larger  than  granulation  cells.     Kidneys  were  ex- 


TUMORS   OF   THE   BLADDER.  35 

tensively  diseased,  and  a  tubercular  mass  undergoing  case- 
ation was  found  in  the  lungs. 

Knowsley  Thornton  speaks  of  having  scraped  away  a  por- 
tion of  a  small  growth  from  the  bladder  with  his  nail  which, 
under  the  microscope,  proved  to  be  a  round-celled  sarcoma. 

Stimson  exhibited  (New  York  Pathological  Society)  the 
bladder  of  a  man  aged  sixty-three,  who  had  complained  of 
frequent  and  painful  passage  of  bloody  urine.  There  was 
a  sarcoma  three  inches  in  diameter,  attached  by  a  pedicle 
as  thick  as  the  finger  to  the  posterior  wall  and  about  four 
inches  above  the  vesical  neck. 

As  secondarily  affecting  the  bladder  we  have  three  cases, 
all  occurring  in  female  children,  and  originatmg  in  the 
vagina.  The  first  case  (Sanger)  is  a  typical  round-celled 
sarcoma  (sarcoma  medullare)  situated  on  the  anterior  co- 
lumnas  rugorum  vaginae  of  a  girl  three  years  old,  which 
later  attacked  the  bladder  and  caused  death  by  perforation 
and  peritonitis.  The  second  (Ahlfeld)  was  a  congenital 
fibro-sarcoma,  which  filled  the  vagina  with  polypoid 
growths  and  also  affected  the  bladder.  The  third  (Solt- 
mann)  was  a  girl  two  and  a  half  years  old  with  a  mucous- 
membrane  sarcoma  of  the  vagina,  characteristic  in  its 
grape-like  form,  leaving  the  uterus  free  and  attacking  the 
bladder. 

From  the  above  cases,  few  as  they  are,  we  learn  that 
sarcoma,  like  carcinoma,  may  be  primary  or  secondary  to 
the  bladder ;  that  it  may  be  of  the  spindle-celled  or  of  the 
round-celled  variety,  and  that  it  may  take  on  the  villous 
form.  With  regard  to  frequency  it  will  appear  that  sar- 
coma of  the  bladder  as  found  in  Uterature  is  rare.  Never- 
theless, seeing  the  resemblance  between  round-celled  sar- 
coma and  encephaloid  cancer  in  regard  both  to  their 
clinical  and  physical  characters,  and  in  the  absence  of. 
microscopical  data,  we  are  with  Gross  in  the  belief,  that 
probably  many  tumors  formerly  described  as  encephaloid 
cancer,  belonged  to  the  variety  of  soft  sarcomata. 


^6  TUMORS   OF   THE   BLADDER. 

Tumors  sometimes  undergo  calcareous  transformation. 
Civiale  mentions  the  case  of  a  negro  aged  fifteen  whom 
Middleton  twice  subjected  to  lithotomy  without  finding  a 
stone.  At  the  autopsy  they  discovered  a  bony  cyst  the 
size  of  a  chestnut.  In  1828  a  woman  appeared  at  L'Hotel 
Dieu  with  S3^mptom  of  stone.  Dupuytren  examined  this 
patient  without  finding  anything.  She  died  of  cystitis,  and 
there  was  discovered  a  pediculated  tumor  the  size  of  a 
large  turkey's  Ggg  entirely  ossified. 

The  etiology  of  tumors  of  the  bladder  is  obscure.  Civi- 
ale and  other  writers  have  endeavored  to  attribute  their 
origin  to  some  continued  local  irritation,  as  the  prolonged 
use  of  the  catheter,  the  presence  of  calculi,  etc.,  but  I  think 
upon  insufficient  grounds.  In  the  majority  of  cases  it  is 
impossible  to  assign  any  injury  or  irritation  as  the  exciting 
cause,  and  in  those  not  very  common  cases  in  which  cal- 
culi co-exist  with  the  new-formation,  the  evidence  is  strong 
that  the  concretion  was  formed  subsequent  to,  rather  than 
before  the  development  of  the  tumor. 

SYMPTOMS. 

All  tumors  of  the  bladder  present,  more  or  less,  sooner 
or  later  the  triple  symptoms — hsematuria,  irritable  bladder, 
and  pain.  We  shall  take  up  those  symptoms  in  the  order 
mentioned,  and  consider  them  as  they  apply  to  each  form 
of  vesical  growth. 

HcBJuaturiayr^iries  in  respect  to  constancy,  time  of  appear- 
ance, and  quantity  of  blood  lost,  with  the  nature  of  the 
tumor.  In  villous  growth  it  is  always  a  most  prominent 
and  unfailing  symptom  ;  it  is  never  absent  during  the  entire 
course  of  the  disease.  This  is  to  be  expected  in  consider- 
ation of  the  peculiar  structure  and  vascularity  of  these 
growths,  made  up  as  they  are  of  delicate  capillary  loops 
which  are  constantly  subjected  to  friction  and  injury  by 
the  powerful  contractions  of  the  bladder.  The  hcematuria 
appears  early.     It  is  often  the  first  and  sometimes  the  only 


TUMORS   OF   THE   BLADDER.  -ly 

symptom  throug-hout  the  complaint,  as  in  the  patients  of 
Partridge  and  Hooper.  The  first  was  a  man  not  in  bad 
health,  with  no  pain,  and  beyond  the  bleedmg  had  no  in- 
dications of  bladder  or  renal  disease.  After  death  from 
■cholera,  there  was  found  a  pedunculated  polypus  covered 
over  its  whole  surface  with  long  villi.  When  the  speci- 
men was  fresh,  the  villi  were  very  florid  and  congested. 
The  mass  was  about  the  size  of  half  a  walnut  and  attached 
by  a  pedicle  of  the  thickness  of  a  crow  quill  to  the  trigone. 
The  mucous  membrane  of  the  bladder  was  perfectly 
healthy. 

Hooper's  patient,  male,  aged  thirty-four.  About  four 
months  before  death,  without  any  premonitory  symptom, 
observed  blood  in  the  urine ;  it  was  unattended  with 
pain  or  any  other  symptom.  The  bleeding  continuing, 
applied  a  month  later  for  medical  advice.  He  described 
the  quantity  of  blood  which  had  been  lost  as  very  great 
and  his  appearance  was  exceedingly  blanched  and  pale. 
He  had  not  lost  flesh,  had  good  appetite,  no  pain  any- 
where, and  excepting  the  haematuria  there  were  no  indi- 
cations of  vesical  disease.  Remedies  were  given  to  arrest 
bleeding,  but  without  avail.  The  man  sank  from  sheer 
bloodlessness.  P.  M.  Every  organ  in  the  body  was  found 
healthy,  with  the  exception  of  the  bladder.  Near  the 
opening  of  the  right  ureter  was  a  peculiar  tufted  growth 
about  the  diameter  of  a  sixpence,  and  one-eighth  of  an  inch 
in  depth  or  thickness,  and  in  its  vicinity  were  two  or  three 
much  smaller  and  more  vascular-looking  tufts,  but  possess- 
ing the  same  general  characters.  Capacity  of  bladder  was 
normal  and  its  coats  healthy. 

In  villous  growths,  blood  may  appear  in  the  urine  at  the 
beginning,  during,  or  at  the  end  of  micturition.  In  the 
commencement  of  the  disease,  it  is  often  observed  that  the 
first  half  or  two-thirds  of  the  urine  passed  is  perfectly 
clear,  while  that  which  appears  towards  the  last  is  bloody, 
or  it  may  be  that  the  flow  remains  clear  to  the  end,  a  few 


-,3  TUMORS   OF   THE   LLADDER. 

drops  of  almost  pure  blood  being  expelled  with  the  coup 
de  piston.  The  latter  phenomenon  is  undoubtedly  due  to 
the  injury  inflicted  upon  the  tumor  by  the  powerful  ex- 
pulsive effort  of  the  bladder  at  the  end  of  micturition,  and 
by  the  forcible  squeezing  of  the  tumor  into  the  vesical  ori- 
fice at  this  time.  For  this  reason,  too,  even  if  the  urine  is 
tinged  throughout  and  from  the  beginning,  that  which 
comes  last  invariably  contains  most  blood. 

The  quantity  of  blood  lost  varies  from  a  mere  parenchy- 
matous oozmg  to  a  free  hemorrhage.  In  the  first  case,  the 
urine  will  be  simply  tinged  with  blood  ;  in  the  latter,  it 
will  be  of  a  dark-claret  or  venous-blood  color,  and  contam 
numerous  and  large  clots.  The  amount  of  hemorrhage  is 
usually  commensurate  with  the  size  of  the  tumor,  although 
death  has  resulted  from  sheer  loss  of  blood  from  a  growth 
not  much  exceeding  the  size  of  a  pea. 

The  hasraaturia  is  apt  to  be  intermittent,  especially  at 
first.  In  the  beginning  of  the  complaint,  it  may  be  noticed 
that  the  urine  is  tmged  with  blood,  but  in  a  few  daj^s  all 
signs  of  hemorrhage  disappear,  and  the  unpleasant  visitor 
is  forgotten  for  possibly  some  weeks  or  even  months,  when 
it  reappears.  Thus  it  may  come  and  go  several  times, 
each  time  the  intervals  becoming  shorter,  until  the  hemor- 
rhage recurs  every  other  day,  every  day,  and,  finally,  with 
every  micturition.  With  the  increase  in  the  frequency, 
there  is  also  generally  an  increase  in  the  quantity  of  blood 
passed. 

The  hemorrhage  seems  to  come  often  without  any 
assignable  or  exciting  cause.  The  urine  may  be  perfectly 
clear  one  day,  while  on  the  next,  under  circumstances  of 
rest,  quiet,  and  treatment,  precisely  the  same  active  hemor- 
rhage may  ensue.  This  was  notably  observed  in  my  pa- 
tient with  villous  cancer  who  had  had  continued  and  quite 
profuse  hemorrhage  for  nearly  three  weeks,  during  which 
time  she  was  constantly  under  the  free  use  of  internal 
astringents,  with  apparently  no  effect.     Her  stomach  re- 


TUMORS   OF    THE    BLADDER.  2g 

belled ;  she  refused  all  food  and  medicine,  and  fell  into  a 
condition  of  collapse  ;  but  from  that  time  the  hemorrhage 
commenced  to  diminish,  and  in  a  few  days  ceased  spon- 
taneously, without  any  treatment  whatever.  Nor  does 
exercise  necessarily  bring  on  a  hemorrhage,  as  shown  in 
Dr.  Hudson's  patient,  who  walked  a  distance  of  nine  miles, 
yet  neither  that  day,  nor  for  three  days  afterwards,  did 
any  appreciable  amount  of  blood  appear. 

In  cancer,  hemorrhage,  although  a  prominent  symptom, 
does  not  occur  until  later  in  the  disease,  because  these 
growths  do  not  bleed  until  some  ulceration  has  taken 
place,  or  until,  perhaps,  the  simple  epithelioma  has  devel- 
oped into  a  villous  growth  by  the  sprouting  of  vascular 
processes  on  its  surface.  Hence,  when  hasmaturia  exists, 
it  is  usually  associated  at  once  (Dickinson's  case  a  remark- 
able exception)  with  irritable  bladder.  In  fact,  frequent 
micturition,  pain,  and  even  catarrh  of  the  bladder  may 
exist  for  some  time  before  hsematuria  occurs.  Indeed,  the 
latter  symptom  sometimes  remains  absent  to  the  end,  as  in 
the  followmg  instructive  cases. 

In  the  patient  of  Sept.  Gibbon,  thei-e  had  been  difficulty 
in  voiding  urine  for  nine  months.  Afterwards,  urine  was 
drawn  off  by  catheter,  but  he  had  no  hcBinaturia.  Death 
occurrmg  from  cancerous  cachexia,  the  bladder  was  found 
occupied  by  a  medullary  growth  about  the  size  of  two  fists. 

In  Ashhurst's  patient,  the  walls  of  the  bladder  were  infil- 
trated with  cancerous  material,  and  the  abdominal  parie- 
tes,  rectum,  and  several  coils  of  small  intestine  were 
invaded,  but  there  had  been  an  entire  freedom  from  hasma- 
turia. The  immediate  cause  of  death  was  attributed  more 
to  pulmonary  disease,  not  cancerous,  than  to  the  vesical 
cancer. 

In  Sanders'  patient,  there  was  extensive  dentritic  cancer, 
involving  the  whole  interior  of  the  bladder,  obstructing 
completely  the  left  ureter,  patient  passed  fragments  of  can- 
cer, and  yet  there  was  no  hsematuna  at  any  time. 


^O  TUMORS   OF   THE   BLADDER. 

Rankin's  patient  had  been  passing  large  quantities  of 
blood,  but  for  at  least  twenty-four  days  previous  to  death 
had  no  hemorrhage.  Lower  part  of  abdomen  was  occu- 
pied by  a  tumor  the  size  of  a  child's  head.  Evidently  the 
bladder  consisted  of  a  sclid  mass,  by  the  occupation  of  its 
left  wall  by  an  encephaloid  cancer.  Iliac  glands  were 
cancerous,  and  the  vesiculae  seminales  and  adjacent  parts 
were  agglutinated  into  a  large  supplementary  tumor. 
Whole  mass  weighed  three  pounds. 

With  regard  to  the  constanc)'^  of  h^ematuria  in  the  other 
varieties  of  tumor,  it  may  be  said  to  depend,  as  in  cancer, 
largely  upon  the  presence  or  absence  of  surface  erosion, 
or  ulceration,  injury  inflicted  by  instrumentation,  etc. 

Fibrous  polypi  are  not  nearly  as  prone  to  bleed  as  mu- 
cous polypi,  and  hemorrhage  is  much  less  characteristic  of 
the  latter  than  of  villous  growths. 

Marchand's  sarcoma  and  Billroth's  mixed  tumor  were 
both  large,  yet  in  neither  was  there  ever  an}^  hemorrhage  ; 
nor  was  the  hemorrhage  other  than  slight  in  the  sarco- 
mata of  Senftleben  and  Heath. 

In  Volkmann's  pure  myoma,  the  urine  became  towards 
the  last  very  bloody ;  but  this  was  accounted  for,  after 
death,  in  the  ulcerated  and  gangrenous  condition  of  the 
tumor  at  its  surface. 

Irritable  Bladder  and  Pain. 

We  have  mentioned  haematuria  first,  because  it  is  the 
most  characteristic  symptom,  not  because  it  is  usually  the 
first  that  appears ;  for  although  in  a  certain  proportion  of 
villous  growths  bloody  urine  is  the  first  symptom  that 
attracts  attention,  in  a  majority  of  these  cases,  as  par 
excellence  in  all  the  other  varieties  of  vesical  tumor,  symp- 
toms of  irritable  bladder  precede  the  appearance  of  blood 
in  the  urine.  In  fact,  frequency  in  micturition  is  often  the 
only  symptom  that  exists  for  months.  This  becomes  more 
and  more  annoying  with  the  progress  of  the  disease,  until 


TUMORS   OF   THE   BLADDER. 


41 


finally  the  bladder  never  feels  entirely  empty,  and  the 
desire  to  void  urine  is  almost  constant.  The  presence  of 
blood  in  the  urine  always  aggravates  the  irritability  of  the 
bladder,  and  if  this  has  not  existed  as  an  independent 
symptom,  it  is  sure  to  be  a  feature  associated  with  hsema- 
turia. 

But  what  an  incomprehensible  organ  the  urinary  blad- 
der is !  So  simple  in  structure,  so  complex  m  mechanism  I 
How  easily,  and  from  what  insignificant  causes  is  it 
excited  to  irritability !  And  yet  how  tolerant  at  times  of 
irritation,  and  even  of  extensive  structural  changes  within 
its  walls ! 

The  following  cases  related  by  J.  Matthews  Duncan  are 
very  instructive  examples  illustrating  the  occasional  toler- 
ance of  the  bladder  to  disease. 

"A  woman  died  under  my  care  from  perimetric  abcess 
and  tubercular  peritonitis.  The  perimetric  abscess  was  a 
consequence  of  parturition,  and  it  burst  into  the  ileum. 
Simultaneously,  with  the  diminution  of  the  abscess,  the 
urine  became  bloody  and  carried  with  it  a  large  amount  of 
pus.  I  never  doubted  that  the  abscess  had  burst  through 
the  bladder.  Pus  was  never  observed  in  the  stools.  A 
post-mortem  examination  was  held,  and  there  was  found 
no  communication  between  the  bladder  and  the  abscess. 
The  bladder  was  only  slightly  contracted,  and  the  whole 
of  its  mucous  membrane  was  dark-red,  in  a  state  of  the 
highest  degree  of  catarrhal  inflammation :  secreting  pus, 
and  also  exuding  blood.  The  woman  had  no  irritability 
of  bladder  ;  she  never  complained  of  that  organ." 

"  Another  case  is  that  of  a  patient  with  great  hsematuria. 
The  case  was  diagnosed  as  being  not  one  of  disease  of  the 
bladder,  on  account  of  the  physical  examination  revealing 
a  healthy  condition,  so  far  as  it  could  be  made  out.  The 
woman  died  suddenly,  and  the  bladder  was  found  to  be 
everj'where  dark-red  ;  and  on  its  internal  surface  there 
were  several  nodules  of  soft  cancer." 


^2  TUMORS   OF   THE   BLADDER. 

As  a  rule,  the  amount  of  irritation  and  functional  dis- 
turbance created  by  a  growth  in  the  bladder  depends 
upon  its  location  and  size.  Tumors  situated  near  the 
vesical  neck,  even  if  small  are  more  apt  to  give  rise  to 
trouble  than  larger  ones  situated  at  the  vertex.  An 
instance  of  extensive  disease  at  the  vertex  of  the  bladder, 
with  remarkable  immunity  from  severe  symptoms,  is  given 
by  Ultzmann.  A  cancer,  the  size  of  the  fist,  situated  at 
the  vertex  of  the  bladder,  perforated  the  abdominal  wall 
above  the  symphysis,  and  formed  a  vesico-abdominal  fis- 
tula, through  which  urme  escaped  as  if  from  a  spring. 
Throughout  this  destructive  process,  the  pain  was  always 
very  moderate.  The  patient  died  of  septicaemia  after 
the  right  inguinal  glands  became  so  much  infiltrated  and 
enlarged  as  to  obstruct  the  circulation  in  the  lower  ex- 
tremity and  transform  the  leg  into  a  swollen,  shapeless 
mass. 

In  malignant  growths,  characteristic  lancinating  or 
darting  pains  may  be  looked  for  in  the  region  of  the  blad- 
der ;  but  the  absence  of  this  symptom  in  several  of  our 
grave  cases  (Heath,  Smyth,  Ashhurst,  Stein)  shows  that 
pain  is  not  pathognomonic  of  vesical  cancer.  Benign 
growths  are  never  in  themselves  painful,  though  by  their 
presence  they  give  rise  to  disturbances  which  often  occa- 
sion much  suffering  and  distress.  If  pain  is  not  associated 
with  frequent  micturition  at  the  outset,  it  very  soon  be- 
comes a  feature  of  the  complaint.  It  is  usually  located  at 
the  vesical  neck  and  perinaeum,  or  commencing  here,  radi- 
ates in  all  directions  ;  but  especially  does  it  extend  along  the 
urethra  to  the  glans  penis,  and  towards  the  rectum.  It  is 
always  worse  during  the  final  act  of  micturition;  and  if 
clots  have  accumulated,  or  have  become  impacted  m  the 
vesical  orifice,  the  expulsion  of  these  is  always  attended  with 
severe  bearing-down  pains,  tenesmus,  and  spasm.  Often 
enough  in  simple  growths,  there  is  no  pain  excepting  dur- 
ing free  hemorrhage  and  the  formation  of  clots  in  the 


TUMORS   OF   THE   BLADDER.  43 

bladder,  which,  when  expelled,  afford  rest  and  freedom 
from  suffering.  Sometimes  there  is  a  more  or  less  steady 
pain  in  the  region  of  the  buttock  and  back  of  the  thigh,  on 
the  side  corresponding  to  the  seat  of  the  disease,  probably 
caused  by  pressure  of  the  tumor  upon  the  sacral  nerves. 
Later  on,  also,  there  may  be  pain  in  the  region  of  the 
kidney,  shooting  downward  toward  the  bladder.  This, 
too,  is  usually  on  the  side  with  the  vesical  growth.  This 
pam  may  be  purely  reflex ;  but  if  persistent,  is  suspicious 
of  a  hydronephrotic  condition  or  structural  change  in  the 
kidney.  Sometimes  there  is  a  sensation  during  micturi- 
tion as  if  something  was  forced  against  the  neck  of  the 
bladder,  Pediculated  growths  are  often  so  situated  that 
they  lie  over  the  vesical  orifice  or  are  propelled  in  that 
direction  during  the  evacuation  of  the  bladder;  and  it 
thus  happens  that  the  flow  of  urine  is  sometimes  momen- 
tarily interrupted,  which,  in  the  absence  of  stone,  is  a 
characteristic  symptom  of  pediculated  tumors.  Further- 
more, these  growths  sometimes  become  engaged  in  and 
block  up  the  vesical  orifice,  either  partially  or  completely, 
occasioning  spasm,  much  difficulty  in  micturition,  and 
retention  of  urine,  requiring  constant  catheterization.  On 
the  other  hand,  they  may  occasion  incontinence  from  the 
gagging  and  dilatation  of  the  vesical  orifice. 

DIAGNOSIS. 

In  point  of  diagnosis  in  the  female,  the  most  unequivocal 
evidence  of  the  disease  is  not  unfrequently  obtained  from 
the  protrusion  of  the  growth  at  the  meatus.  This  was 
manifest  in  the  cases  of  Warner,  Pleininger,  Warner,  Thei- 
nemann,  Shaw,  Senftleben,  Guersant,  Birkett,  Bishop, 
Marsh,  Schatz,  Winckel,  Godson,  Barton.  In  one  or  two 
instances,  the  protrusion  was  incomplete,  that  is,  the 
growth  extended  into  the  urethra,  but  not  beyond ;  in 
all  the  others,  the  tumors  appeared  external  to  the  mea- 
tus.    In  some  cases,  the  protrusion  was  constant,  but  most 


44  TUMORS   OF    THE   BLADDER. 

frequently  the  growths  appeared  only  with  straining  at 
stool  or  during  micturition.  Pleininger's  patient  was  an 
exception  to  this  rule ;  she  had  prolapsus  of  rectum  dur- 
ing stool,  and  the  projecting  mass  from  the  urethra, 
which  was  of  the  form  and  size  of  a  strawberry,  always 
returned  with  the  descent  of  the  gut.  In  some  instances, 
the  urethra  was  enormously  dilated  by  the  descending 
growths,  sometimes  only  at  its  upper  portion,  some- 
times its  entire  length.  In  Schatz's  patient,  the  lower 
fourth  of  the  urethra  had  retained  its  normal  calibre,  but 
the  canal  behind  this  was  dilated  to  the  diameter  of  the 
finger,  in  which  projected  a  tumor  the  size  of  a  goose's  egg. 
In  Theinemann's  patient,  a  polypus  the  size  of  a  hen's  egg 
protruded  from  the  urethra,  which  could  readily  be  entered 
with  the  two  fingers.  In  Marsh's  patient,  the  polypi  so  far 
distended  the  urethra  that  "  at  first  this  canal  was  mistaken 
for  the  vagina." 

In  all  doubtful  or  obscure  cases,  the  passage  of  portions 
of  a  growth  with  the  urine  is  a  most  fortunate  circumstance, 
as  it  affords  not  only  positive  evidence  of  the  existence  of 
a  tumor,  but,  which  is  still  more  important,  may  determine 
the  propriety  of  attempting  its  removal.  This  is  happily 
not  a  very  unfrequent  occurrence.  Kocher,  Bryant,  Bren- 
necke,  Thompson,  Harrison,  Hill,  Ultzmann,  Dickinson, 
Alexander,  Sanders,  Hicks,  Marcacci,  Senftleben,  Volk- 
mann,  Winckel,  and  others,  make  special  mention  of  having 
observed  portions  or  fragments  of  tumor  in  the  urine. 
Winckel's  patient  showed  him  a  mass  of  warty  bodies, 
nearly  the  size  of  a  hazel-nut,  and  in  quantity  sufficient  to 
fill  a  medium-sized  tumbler,  which  had  come  away,  from 
time  to  time,  by  the  urethra,  and  it  was  said  that  eight 
months  afterwards  a  mass  came  away  large  enough  to  fill 
a  glass  of  one  hundred  grammes  capacity.  The  portion  of 
Volkmann's  tumor  thus  passed  was  the  size  of  the  little 
finger. 

The  spontaneous  expulsion  of  portions  of  tumor  is  gen- 


TUMORS    OF    THE    BLADDER.  4- 

erally  followed  by  great  relief  to  the  patient,  and  in  some 
instances  permanent  cure  has  thus  been  effected.  Ultz- 
mann  speaks  of  an  elderly  man,  much  exhausted  from  hee- 
maturia,  from  whom  villous  masses  came  away  ;  the  patient 
remaining-  well  three  years  afterward.  Bryant  mentions  a 
case  of  Hicks'  in  which  a  large  mass  was  passed  with  ap- 
parently similar  result.  But  the  most  remarkable  instance 
is  that  of  Brennecke.  A  woman,  aged  thirt3'-four,  found 
herself  in  the  sixth  month  of  her  fourth  pregnancy,  in  the 
beginning  of  May,  i§76;  for  about  three  weeks  suffered 
with  an  intense  vesical  catarrh,  and  occasionallv  with  sud- 
den stoppage  in  the  evacuation  of  urine.  Dr.  B.  was  called 
to  see  her  on  account  of  some  bearing-down  pains.  After 
fifteen  or  twenty  hours  of  tormenting  pain,  there  was  ex- 
pelled from  the  urethra  a  tumor  fully  the  size  and  shape  of 
the  kidney  of  a  new-born  child.  From  that  moment  the 
symptoms  of  vesical  catarrh  ceased.  The  pregnane}^  went 
on  to  full  term,  and  she  gave  birth  to  a  living  boy.  The 
report  was  made  April  12th,  1879,  ^^^  the  woman  remained 
well  up  to  that  time.  The  tumor  is  said  to  have  been  a 
fibro-myxoma  originating  from  the  mucous  membrane  or 
the  submucous  tissue  of  the  bladder. 

Small  polypoid  or  pediculated  growths  becoming  ac- 
cidentally engaged  in  the  eye  of  a  catheter  have  been 
removed  by  avulsion  and  have  thus  served  to  establish 
the  diagnosis,  and  in  some  cases  permanent  recovery 
seems  to  have  resulted.  Mass  says  he  has  removed 
mucous  polypi  in  this  manner  from  three  patients.  The 
first,  a  man  aged  fifty -three,  suffered  with  repeated  hsema- 
turia,  etc.  On  washing  out  the  bladder,  the  outflow  of 
urine  was  suddenly  arrested  by  the  impaction  in  the  eye  of 
the  catheter  of  a  mucous  polypus  of  the  size  of  a  hazel-nut, 
with  a  short,  broad  pedicle;  a  second  and  similar  growth 
was  removed  at  the  same  sitting  and  in  the  same  way.  The 
patient  remained  free  from  a  repetition  of  the  hsematuria. 
In  the  second  patient,  aged  thirty-three,  a  large  single 


46  TUMORS    OF    THE    BLADDER. 

catheter  was  passed,  to  which  was  attached  an  arrange- 
ment of  elastic  tubing,  and  a  funnel,  by  means  of  which  fluid 
could  be  injected  or  withdrawn  from  the  bladder  at  plea- 
sure. After  a  few  injections,  an  elongated  polypoid  growth 
was  caught  in  the  eye  of  the  catheter  and  extracted  as  in 
the  former  case.  In  the  third  patient,  aged  thirty-eight, 
injections  were  made  in  the  same  manner,  and  a  small  po- 
lypus with  a  long  thin  pedicle  soon  stopped  up  the  eye  of 
the  catheter  and  was  removed, 

Ultzmann  refers  to  a  man,  aged  sixty,  with  haematuria, 
dysuria,  etc.  He  introduced  a  metal  catheter,  and  re- 
moved bloody  urine,  and  in  attempting  to  withdraw  the 
instrument,  felt  that  it  was  held  ;  removing  it,  however, 
he  saw  projecting  from  the  eye  of  the  catheter  a  villous 
growth  three  centimetres  in  length.  The  man  did  not 
suffer  any  more  from  dysuria  or  hsematuria.  Six  months 
later  he  died,  as  it  was  said,  from  disease  of  the  stomach. 

Mr.  Bryant  also,  while  catheterizing  a  female  child,  ac- 
cidentally pulled  away  a  small  villous  growth  which  had 
become  caught  in  the  eye  of  the  instrument. 

All  the  forms  of  tumor  found  in  the  bladder,  papillomata, 
polypi,  sarcomata,  carcinomata,  and  even  myomata,  have 
manifested  their  presence  by  the  appearence  of  small  frag- 
ments of  their  structure  in  the  urine,  but  this  is  a  special 
attribute  of  villous  growths,  both  simple  and  malignant, 
whose  characteristic  appearance  can  generally  be  recog- 
nized under  water  by  the  unaided  sight.  If  the  particles 
are  small,  and  the  urine  very  bloody,  it  may  be  very  difficult 
to  find  them.  They  should  always  be  sought  for,  if  possi- 
ble during  the  intervals  of  hemorrhage,  when  the  urine  is 
clear.  From  coagula,  however,  they  may  be  distinguished 
in  that  they  are  of  a  lighter  color,  and  have  a  more  firm, 
fleshy  consistence. 

With  regard  to  the  histological  data,  obtained  by  the 
microscopic  examination  of  minute  particles  of  villous 
tissue,  it  is  not  to  be  expected  that  the  villous  structure 


TUMORS   OF    THE    BLADDER.  47. 

will  always  present  its  characteristic  appearance  un- 
changed. This  may  be  expected  when  larger  portions 
have  recently  been  detached  and .  removed  fresh  with  the 
urine;  but  the  filamentous  shreds,  so  often  found,  have 
been  detached  by  a  slower  necrotic  process,  and  no  longer 
present  the  perfect  capillary  loop,  with  its  epithelial  cov- 
ering. Distinct  and  well-preserved  villi  are  more  apt  to 
be.  found  as  coming  from  benign  villous  growths  than  from^ 
villous  cancer,  because  the  former,  having  a  thinner  epi- 
thelial covering,  its  structure  is  more  apparent ;  it  is  less 
frequently  subjected  to  the  disintegrating  influence  of 
ammoniacal  urine,  and  the  field  of  observation  is  not  so 
apt  to  be  obscured  by  the  presence  of  pus,  ammonio-mag- 
nesian   phosphates,    etc.,    as   it   is   in    malignant    disease. 

Ultzmann  calls  attention  to  a  condition  of  urine  known 
as  fit^nuria  as  an  important  diagnostic  feature  in  villous 
growths.  According  to  this  writer,  the  urine  when  first 
passed,  although  very  watery  (diinnfliissig)  and  of  a  red- 
dish-yellow color,  coagulates  after  a  few  minutes  into  a 
glutinous  mass,  which  can  scarcely  be  drawn  from  the 
glass.  It  is  especially  to  be  noticed  that  such  urine  does 
not  contain  much  blood,  as  shown  by  the  color,  which  is 
not  blood-red,  but  a  yellow-reddish  hue,  and,  therefore,  the 
quantity  of  coagulum  is  not  in  proportion  to  the  quantity 
of  blood  present  in  the  urine.  Furthermore,  the  coagula 
are  formed  in  a  few  seconds  after  the  urine  has  passed, 
and  may  subsequently  be  rendered  fluid  by  a  little  shak- 
ing ;  while  blood  not  only  requires  a  longer  time  to  coag- 
ulate, but  does  not  become  fluid  by  stirring.  Ultzmann 
says  that  he  has  observed  this  condition  of  urine  in  three 
cases  of  villous  growths. 

In  my  own  patient  with  villous  cancer,  I  observed  this 
remarkable  condition  of  urine  almost  constantly  during 
her  illness ;  at  times  even  when  it  could  scarcely  be  said 
that  the  urine  was  colored,  light  particles  of  coagula  were 
found  floating  therein  in  abundance,  and  when  picked  out 


48  TUMORS   OF    THE    BLADDER. 

and  placed  under  the  microscope,  presented  an  extremely 
delicate  interlacing  network  of  fibres,  in  the  meshes  of 
which  were  crystals  of  triple  phosphates.  The  urine  con- 
tained remarkably  few  pus-corpuscles,  and  the  reaction  was 
never  more  than  feebly  alkaline.  Ultzmann's  theory  with 
respect  to  this  phenomenon  is,  that,  owing  to  the  powerful 
spasmodic  contractions  of  the  bladder,  the  return  circula- 
tion from  the  villi  is  interfered  with,  and  turgescence  of 
the  vascular  loops  occurs.  If  the  blood-pressure  is  very 
great,  the  vessels  rupture,  and  hemorrhage  ensues  ;  if  the 
tension  is  not  sufficient  to  cause  rupture  of  the  vessels,  a 
transudation  of  plasma  occurs,  whose  fibrin  coagulates  on 
the  emission  of  the  urine.  This  increased  vascular  tension 
also  accounts  for  the  presence  of  more  albumen  in  the 
urine  than  would  correspond  to  the  quantity  of  blood  and 
pus  present.  w 

With  regard  to  the  evidence  furnished  by  the  micro- 
scopic examination  of  the  urine  in  cancer,  it  may  be  said 
that,  when  associated  with  hsematuriaand  other  symptoms, 
the  presence  of  numerous  and  irregularly-shaped  epithe- 
lial cells  is  highly  confirmatory  of  the  existence  of  cancer, 
but  the  presence  in  the  urine  of  such  epithelia  is  sometimes 
very  misleading,  and  the  microscope  cannot  be  relied  upon 
as  a  means  of  diagnosis,  unless  tangible  fragments  are  passed 
with  the  urine — a  circumstance  not  of  frequent  occurrence 
in  this  class  of  tumors.  Dickinson  says,  "  No  isolated  or 
detached  cells  found  in  the  urine  can  be  regarded  as  proof 
of  cancer  in  the  urinary  tract ;  while  the  absence  of  such 
cells  present  no  argument  in  favor  of  the  freedom  of  the 
bladder  or  kidneys  from  malignant  disease.  Under  cir- 
cumstances of  irritation  and  disturbance,  large  cells,  pre- 
senting quite  the  ideal  of  cancer  cells  of  all  shapes  and 
character,  regular  and  irregular,  rounded,  angular,  and 
elongated,  are  occasionally  thrown  off  in  abundance  from 
various  parts  of  the  urinary  mucous  membrane.  Patients 
who,  upon  the  evidence  of  urine  presenting  such  appear- 


TUMORS   OF   THE   BLADDER. 


49 


ance,  have  been  convicted  of  cancer,  have  been  known 
to  get  well  and  remain  so."  Sir  Henry  Thompson  says, 
"  Some  of  the  best  '  cancer  cells '  I  ever  saw  in  my  life  were 
collected  from  a  patient's  urine  and  placed  under  the 
microscope  by  an  eminent  microscopic  observer,  for  the 
purpose  of  a  very  important  consultation.  After  a  careful 
examination  of  the  patient,  I  admitted  the  beauty  and  perf  ec. 
tion  of  the  microscopic  observation,  but  on  larger  grounds 
denied  the  existence  of  cancer  in  the  bladder,  and  the  ulti- 
mate result,  happily  for  the  patient,  confirmed  that  view 
and  disproved  the  cell." 

In  the  four  cases  of  tumor  which  have  come  under  my 
observation,  frequent  and  daily  examinations  were  made, 
and  in  only  one,  in  which  flocculi  were  visible  to  the  naked 
eye,  was  ever  any  positive  evidence  of  the  disease  mani- 
fest in  the  urine.  Exceptional  then,  as  this  is,  the  two  fol- 
lowing cases  of  Dickinson  and  Sanders  are  interesting 
instances  in  which  the  diagnosis  of  cancer  was  clearly 
made  by  the  microscope.  The  first  is  especially  instruct- 
ive in  that  the  presence  of  the  growth  was  recognized 
even  before  there  were  any  subjective  symptoms  pointing 
to  the  disease. 

On  July  24th,  1868,  Dr.  Dickinson  was  called  upon  to 
examine  some  blood-tinged  urine  which  contained  small, 
soft,  buff-colored  lumps,  that  had  very  much  the  appear- 
ance of  fibrinous  coagula,  for  which  they  were  at  first 
mistaken.  These  masses  had  drawn  attention  by  briefly 
obstructing  the  urethra  during  their  passage.  The  urine 
had  been  passed  by  a  man  aged  fifty-one,  in  robust  and 
vigorous  health.  Excepting  what  had  been  observed  in 
the  urine,  there  had  been  no  symptoms  pointing  to  the 
urinary  organs,  or  to  any  other  part  of  the  body,  as  the 
seat  of  disease.  On  placing  a  portion  of  one  of  the  soft 
hiasses  under  the  microscope,  it  was  found  to  belong  to  a 
malignant  tumor,  apparently  of  the  encephaloid  kind ;  but 
so  complete  was  the  absence  of  bladder  symptoms,  and  so 
4 


CO  TUMORS   OF    THE   BLADDER. 

perfect  the  apparent  health  of  the  patient,  that  this  view 
of  the  case  was  at  first  received  with  incredulity ;  but 
towards  the  end  of  August  it  was  found  that  carriage 
exercise,  to  which  the  patient  had  been  much  used,  had  to 
be  given  up  in  consequence  of  the  pain  it  produced.  The 
bladder  became  the  seat  of  more  or  less  constant  pain,  and 
at  intervals  of  from  two  to  three  weeks,  irregular  lumps  of 
soft  matter,  looking  very  much  like  cerebral  tissue,  mixed 
with  blood  and  phosphatic  deposit,  and  of  all  sizes  up  to 
a  culinary  bean  were  passed,  always  with  great  relief  of  the 
pain.  Blood  was  now  frequently  passed,  and  as  the  winter 
approached,  the  general  health  gradually  broke  down.  The 
bladder  became  exceedingly  irritable,  and  micturition  was 
attended  with  some  pain.  The  patient  was  gradually 
worn  out  by  his  sufferings,  and  died  March  24th,  1869. 
There  was  no  autopsy  held  ;  but  as  he  says,  it  is  not  possi- 
ble to  doubt  either  the  seat  or  nature  of  the  tumor. 

Sanders'  patient,  male,  aged  forty-three,  passed  frag- 
ments of  cancer,  sometimes  of  small  size,  like  mere  shreds, 
at  other  times  forming  C3dindrical  plugs  about  an  inch 
long,  which  often  became  impacted  in  the  urethra  and 
obstructed  the  flow  of  urine.  There  was  no  hsematuria  at 
any  time.  The  post-mortem  showed  extensive,  dentritic 
cancer,  involving  the  whole  interior  of  the  bladder. 

In  the  male,  there  is  often,  much  difiEculty  in  ascertain- 
ing the  presence  of  a  tumor  in  the  bladder.  The  ordinary 
digital  examnnation  is  often  fruitless.  If  the  tumor  is 
large,  and  situated  at  the  vertex,  it  may  be  felt  through 
the  abdominal  parietes ;  if  situated  at  the  bas  fond,  and  is 
sufficiently  large,  or  has  infiltrated  the  coats  of  the  bladder, 
it  may  be  recognized  by  the  finger  in  the  rectum.  But 
tumors  rarely  grow  from  the  superior  fundus  of  the  blad- 
der ;  and,  what  is  of  still  greater  importance,  those  tumors 
which  are  most  amenable  to  radical  treatment  by  extirpa- 
tion, and  which  it  is  especially  important  to  discover  as 
early  as  possible,  are  usually  soft,  pediculated   growths, 


TUMORS   OF   THE   BLADDER.  cr 

which  do  not  involve  the  thickness  of  the  vesical  walls, 
and  which  readily  escape  recognition  by  ordinary  rectal 
examination.  Even  in  the  female,  where  the  bladder  is 
certainly  more  accessible  to  palpation  through  the  vagina, 
such  tumors  constantly  escape  detection. 

In  the  male  especially,  but  also  in  the  female,  the  bi- 
manual method  of  palpation  should  always  be  instituted. 
This  consists  in  introducing  one  or  two  fingers  as  far  as 
possible  into  the  rectum,  or  into  the  vagina,  and  while 
palpating,  an  assistant,  with  both^  hands  flat  on  the  hypo- 
gastrium,  presses  downwards  and  backwards  with  the 
ball  of  the  hand  ;  the  surgeon  now  crowds  one  hand  under 
the  hands  of  the  assistant,  and  thus  manipulates  the  growth 
between  his  fingers.  In  this  manner,  Volkmann  felt  a 
tumor  through  the  rectum,  which  was  situated  at  the  ver- 
tex of  the  bladder,  and  which  before  had  entirely  eluded 
his  search.  If  necessary,  the  entire  hand,  if  not  too  large, 
can  be  introduced  into  the  rectum,  when  the  moderately 
distended  bladder  is  easily  recognized  as  a  fluctuating 
tumor  behind  the  prostate,  and  may  be  thoroughly  pal- 
pated for  the  detection  of  a  foreign  growth.  This  exami- 
nation can  scarcely  fail  to  afford  intelligence  of  the  pres- 
ence of  a  tumor.  The  patient  should  be  angesthetized, 
and  the  introduction  of  the  hand  into  the  rectum  should 
be  very  gradual,  passing  first  two,  then  three  and  four 
fingers,  and  finally,  the  entire  hand.  The  introduction  is 
facilitated  by  pressure  with  the  other  hand  over  the  abdo- 
men ;  and  unless  the  hand  is  very  large,  which,  perhaps, 
should  not  exceed  nine  inches  in  circumference,  or  its 
introduction  is  too  rapid,  the  sphincter  will  remain  intact, 
and  no  incontinence  of  fseces  or  other  trouble  will  super- 
vene. 

In  exploring  the  interior  of  the  bladder,  a  short-beaked 
catheter  or  sound  should  be  employed,  because  it  admits 
of  greater  freedom  of  movement,  and  can  be  better  made 
to  sweep  over  the  walls  and  fundus  of  the  viscus.     The 


5: 


TUMORS   OF    THE   BLADDER. 


exploration  should  always  be  conducted  with  the  finger  in 
the  rectum  or  vagina,  and,  if  possible,  still  further  assisted 
by  crowding  down  the  bladder  by  pressure  from  above. 
We  will  thus  rarely  fail  to  make  out  the  presence  of  a 
tumor.  Certain  small,  soft  growths,  not  offering  any  resist- 
ance to  the  instrument,  and  small  tumors  situated  on  the 
anterior  wall  have  more  than  once  escaped  the  tactiLS 
erudittLs ;  but  ordinarily,  the  deviation  of  the  beak  of  the 
instrument  to  one  side  or  the  other,  the  obstacle  encoun- 
tered in  its  movements^the  thickness  and  consistence  of 
the  structures  interposed  between  the  finger  and  the  in- 
strument, the  production  of  pain  by  the  impingement  of 
the  sound  against  the  tumor,  the  hsematuria  induced  by  the 
manipulation,  especially  if  the  tumor  is  of  the  villous 
variety,  will  all  tend  clearly  to  define,  not  only  the  exis£- 
ence  of  a  tumor,  but  also  its  location,  mobility,  and,  to 
a  certain  extent,  its  size. 

But  whatever  difficulty  may  present  in  obtaining  the 
desired  information  in  the  male,  in  the  female  all  doubt 
may  be  set  aside  by  dilating  the  urethra  and  making  the 
bladder  accessible  to  direct  exploration.  It  is  thus  scarcely 
possible  to  overlook  the  presence  of  a  tumor  in  the  blad- 
der ;  and  if  there  is  any  suspicion  even  of  the  existence 
of  a  growth,  such  an  examination  should  be  made  at  once, 
and  the  result  will  be  that  much  suffering  will  be  avoided, 
and,  perhaps,  many  a  life  saved. 

The  principal  objection  that  might  be  urged  against  this 
method  of  diagnosis  is  the  danger  of  producing  laceration 
of  the  urethra  and  permanent  incontinence  of  urine.  I 
cannot  deny  that  serious  accidents  have  happened  even  in 
experienced  hands,  but  when  we  know  with  what  instru- 
ments this  operation  is  often  performed  we  can  only  wonder 
that  more  women  have  not  been  injured  for  life.  Every 
conceivable  instrument  that  is  capable  of  stretching,  from 
the  various  branched  uterine  dilators  of  EUinger,  Atlee, 
etc.,  down  to  even  sequestrum  and  bullet  forceps,  have  been 


TUMORS    OF    THE   BLADDER.  53 

employed  at  one  time  and  another  as  dilators  for  the  deli- 
cate female  urethra.  Is  it  to  be  wondered  at  that  the 
vesical  sphincter  is  ruptured  by  such  rude  manipulation? 
The  dilatation  of  the  female  urethra  is  one  of  the  import- 
ant operations  in  surgery,  and  requires,  even  with  the 
most  approved  instrument,  the  exercise  of  every  care,  good 
judgment,  gentleness  and  patience.  Digital  dilatation,  a 
method  adopted  by  some  surgeons,  is  not  much  safer. 
Several  cases  are  known  to  me,  in  which  very  troublesome 
incontinence  of  urine  has  followed  this  practice.  In  a 
patient  of  my  own,  the  urethra  was  suddenly  torn  when 
every  care  was  being  taken  to  avoid  it,  and  although  the 
woman  ultimately  recovered,  for  weeks  she  suffered  with 
incontinence,  and  I  was  much  concerned  as  to  whether  she 
would  ever  regain  the  control  of  her  sphincter, 

Simon,  who  did  so  much  to  popularize  this  operation, 
used  a  series  of  plug-shaped  specula  of  seven  different  sizes, 
ranging  from  three-fourths  to  two  centimetres  in  diameter. 
These  are  introduced  and  withdrawn  one  after  the  other, 
until  the  required  dilatation  is  attained.  The  greater 
safety  of  these  plugs  over  the  sharp  edged  dilators  above 
mentioned  is  too  apparent  to  need  comment.  But  I  think 
we  have  a  better  substitute  in  an  instrument  which  I  had 
constructed  about  a  3^ear  and  a  half  ago,  and  which  has 
since  been  freely  used  by  myself  and  others  in  this  city 
with  every  satisfaction,  and  with  absolutely  no  ill  report 
irom  any  source.  Its  advantages  require  but  to  be  pointed 
out  to  be  at  once  appreciated.  It  consists  (Plate  xi..  Fig. 
i)  of  a  metal  tube  three  and  a  half  inches  in  length,  with 
an  obturator,  elastic  and  conical  at  the  point,  which  pro- 
jects an  additional  inch  beyond  the  distal  end,  and  which 
serves  to  facilitate  the  introduction  of  the  instrument. 
One  inch  from  the  proximal  end  is  a  handle  that  supports 
a  graduated  bar  and  thumb  screw,  by  means  of  which  the 
expansion  of  the  instrument  is  effected.  When  closed  it  is 
•thirty-nine  millimetres  in  circumference,  and  is  capable  of 


t^j^  TUMORS   OF   THE   BLADDER. 

expansion  to  six  and  a  half  centimetres.  Fig.  4  represents 
a  vertical  section  of  the  instrument  closed.  At  Fig.  2  it  is 
seen  expanded  to  fifty  millimetres,  and  Fig.  3  shows  a  verti- 
cal section  in  complete  expansion,  viz.,  six  and  a  half  cen- 
timetres. From  this  it  will  be  seen  that  the  expansive 
force  of  the  instrument  is  distributed  as  equally  as  possible 
over  all  parts  of  the  circumference  of  the  urethra  by  smooth 
rounded  blades,  and  not  upon  two  or  three  points  or  sides 
of  the  canal.  Furthermore,  the  dilatation  can  be  effected 
very  gradually,  and  with  absolute  precision,  the  degree  of 
expansion  being  determined  by  the  graduated  bar  with  the 
greatest  accuracy,  even  to  a  millimetre. 

In  this  manner  we  conform  to  the  conditions  by  which 
alone  a  maximum  degree  of  dilatation  without  laceration 
can  be  attained.  Indeed,  the  tearing  or  rupturing  of  the 
urethra,  which  with  other  instruments  is  almost  inevitable 
when  thorough  dilatation  is  effected,  and  the  incontinence 
of  urine  which  such  an  injury  often  entails,  will  by  this,  if 
by  any  method,  be  avoided. 

Owing  to  the  peculiar  conformation  of  the  instrument,  it. 
creates  very  little  pain,  even  when  dilated  to  its  utmost 
capacity.  I  have  operated  in  this  way  a  number  of  times 
without  using  any  anaesthetic.  The  instrument  is  also  an 
admirable  speculum  by  which  a  most  satisfactory  view  of 
the  interior  of  the  bladder  can  be  obtained  by  means  of 
reflected  light. 

The  following  would  be  the  method  of  procedure  in  a 
suspected  case  of  tumor  of  the  bladder.  The  patient  being 
on  the  back  or  on  the  side,  and  anassthetized,  the  instrument 
is  introduced  and  rapidly  dilated  to  a  point  at  which 
some  resistance  is  felt,  when  the  dilatation  is  proceeded 
with  more  slowly  and  cautiously,  the  canal  being  stretched 
a  few  millimetres  at  a  time,  the  force  exerted  being  in  in- 
verse proportion  to  the  resistance  to  be  overcome,  and  a 
sufficient  interval  of  time  always  allowed  to  elapse  for  the 
tissues  to  relax  before  further  dilatation  is  made.     In  this. 


TUMORS   OF   THE   BLADDER. 


55 


Plate  XI. 


Author's  female  urethral  dilator  and  speculum. 


r5  TUMORS   OF   THE   BLADDER. 

manner  the  instrument  is  gradually  expanded  to  the  cir- 
cumference of  the  index  finger,  or  if  need  be  to  its  fullest 
capacity,  which  is  six  and  a  half  centimetres. 

It  must  not  be  forgotten  that  the  dilatability  of  the 
female  urethra  varies  much  with  the  individual  and  with 
age.  In  some  persons,  the  expansion  can  be  carried  to  the 
fullest  extent  of  the  instrument,  with  little  pain  and  with 
little  delay,  while  in  others,  the  rigidity  of  the  meatus, 
which  is  the  narrowest  and  most  unyielding  part  of  the 
urethra,  is  extreme,  and  the  danger  of  laceration  great. 
According  to  Simon,  the  highest  degree  of  complete  in- 
nocuous dilatation  is  6.3  centimetres  in  circumference,  7 
centimetres  at  the  furthest ;  in  girls  of  from  11  to  15,  it  is 
reached  at  a  circumference  of  4.7  to  5.6  cenrimetres ;  in 
girls  of  from  15  to  20,  at  5.6  to  6.3  centimetres  in  circum- 
ference. 

While  this  is,  no  doubt,  the  safe  limit,  we  must  know 
that  the  urethra  is  capable  of  much  greater  dilatation, 
without  producing  permanent  incontinence.  In  the  case 
of  Winckel,  finger  and  instrument  had  been  in  the  bladder, 
the  urethral  mucous  membrane  was  fissured,  and  yet  none 
of  the  one  hundred  and  fifty  grammes  of  water  injected 
after  the  operation  escaped  from  the  bladder.  In  the 
case  of  Schatz,  although  during  the  operation  the  ure- 
thra was  dilated  to  an  extent  admitting  two  fingers, 
she  could  retain  her  water  one  hour  after  the  operation, 
and  afterwards  two  and  three  hours ;  from  the  seventh 
day  she  micturated  once  at  night  and  twice  during  the 
day.  There  was  pain  only  on  the  first  day  during  mictu- 
rition. We  could  cite  other  instances  in  which  both  in- 
dices were  inserted  into  the  bladder  without  any  serious 
injury  resulting. 

Simon  always  divided  the  meatus  with  scissors  before 
commencing  dilatation,  making  two  lateral  slits  of  one- 
quarter  centimetre  in  the  upper  margin,  and  one  down- 
wards of   a  half   centimetre  in  depth.     With  the  instru- 


TUMORS   OF   THE   BLADDER.  57 

Tnent  just  described,  I  have  thus  far  had  no  occasion  to  do 
this,  but  if  the  parts  are  at  all  rigid,  there  is  no  objection  to 
slitting  the  meatus,  while  the  urethra  is  thereby  just  so 
much  shortened,  and  the  finger  can  be  introduced  further 
into  the  bladder. 

The  urethra  being  dilated,  the  instrument  is  withdrawn, 
the  index  and  middle  fingers  are  introduced  into  the  ure- 
thra and  vagina  respectively,  and  simultaneously  carried 
up  until  arrested  by  the  urethro-vaginal  septum.  By  pass- 
ing the  middle  finger  into  the  vagina,  the  index  can  be  ad- 
vanced at  least  one  centimetre  further  into  the  bladder  than 
by  the  usual  way  of  exploring.  With  supra-pubic  pressure 
made  with  the  other  hand,  the  finger  can  sweep  over  the 
mucous  surface  and  the  presence  of  a  growth,  its  location, 
size,  and  extent  of  attachment  may  be  exactly  determined. 
If  desired,  a  small  portion  of  the  tumor  may  be  detached 
or  scraped  off  with  the  finger-nail  or  sharp  spoon,  and 
submitted  to  further  examination  by  the  microscope,  or 
the  bladder  may  be  illuminated  by  reflected  light  thrown 
in  through  the  speculum. 

With  regard  to  the  question  of  diagnosis  as  between 
simple  and  malignant  growths,  the  former  do  not  produce 
the  same  pathogenetic  changes  in  the  surroundirg  mucous 
membrane  of  the  bladder  as  do  the  malignant  tumors ; 
hence,  there  are  rarely  any  secondary  symptoms  of  inflam- 
mation or  catarrh  of  the  bladder  (except  as  set  up  by  the 
surgeon's  unnecessary  and  prolonged  instrumental  man- 
ipulation), and  at  the  autopsy  the  mucous  membrane  is 
generally  found  healthy.  In  the  two  cases  of  myoma, 
also,  it  is  interesting  to  note  the  comparative  absence  from 
the  urine  of  products  of  inflammation.  Billreth's  boy  suf- 
fered for  ten  months  with  frequent  and  painful  micturition, 
and  yet  the  urine  remained  feebly  acid,  and  contained  but 
a  moderate  quantity  of  pus.  Volkmann's  man  suffered 
with  frequent  micturition,  tenesmus,  hemorrhage,  and 
strangury  for  six  months,  but  had  neither  pus  nor  mucus 


c8  TUMORS   OF   THE   BLADDER. 

in  his  urine.  The  vesical  trouble  was  entirely  due  to  the 
obstructive  effect  produced  by  so  large  a  tumor,  and  at  the 
autopsy  the  mucous  membrane  was  found  healthy. 

In  villous  growths  especially,  the  intermittent  character 
of  the  symptoms  is  a  peculiar  feature.  The  improvement 
which  is  at  once  manifest  with  the  cessation  of  hemor- 
rhage, and  the  absence  of  any  pain  or  discomfort  during 
the  interv^als  of  hemorrhage,  are  characteristic. 

In  malignant  tumor,  we  have  the  existence  of  cancer  of 
the  uterus,  prostate,  or  other  surrounding  organ,  or,  per- 
chance, at  some  remote  part  of  the  body,  to  point  to  the 
disease  in  the  bladder,  or  there  may  be  a  decided  heredi- 
tary tendency  to  cancer.  The  touch  is  more  certain  to 
recognize  the  presence  of  a  nialignant  growth,  because 
these  tumors  are  more  frequently  solid,  and  infiltrate  the 
coats  of  the  bladder.  A  comparison  of  the  duration  of 
the  complaint  with  the  character  and  severity  of  existing 
symptoms,  will  mark  a  more  rapid  progress  than  is  ob- 
served in  benign  tumors. 

The  secondary  symptoms  of  chronic  inflammation  or 
catarrh  of  the  bladder  are  characteristic ;  hence,  all  the 
symptoms  are  more  distressing  and  more  enduring. 

But,  while  the  more  aggravated  the  secondary  symp- 
toms the  less  the  probability  of  the  same  being  caused  by 
other  than  malignant  growths,  these  symptoms  may  attain 
such  a  degree  of  intensity  as  to  mask  the  original  disease, 
and  render  diagnosis  difficult ;  especially  so  in  the  absence 
of  the  most  characteristic  symptom — hsematuria — as  ob- 
served in  the  cases  above  cited.  But  hsematuria  is  excep- 
tionally absent,  and  this,  together  with  the  other  symptoms 
mentioned,  the  lancinating  and  darting  pains,  the  glandu- 
lar involvement,  and  the  appearance  of  cancerous  cachexia, 
will  make  the  diagnosis  of  cancer  conclusive.  With  refer- 
ence to  the  appearance  of  cancerous  cachexia,  however,  I 
should  say  that  this  is  at  times  very  deceptive.  Those 
suffering  from  non-malignant  tumors  often  present  an  ap- 


TUMORS   OF   THE   BLADDER.  eg 

pearance  not  unlike  that  observed  in  cancerous  infection. 
In  consequence  of  the  prolonged  hemorrhage,  pain,  dis- 
turbed rest,  and  impaired  nutrition,  the  subjects  become 
fearfully  anaemic,  and  present  an  appearance  which  might 
be  easily  attributed  to  cancerous  infection. 

If  the  seat  of  the  tumor  is  not  accessible  to  the  sense  of 
touch  or  appreciable  by  instrumental  contact,  no  frag- 
ments of  tumor  have  passed  the  urethra,  and  the  urinary 
sediments  have  afforded  no  clue  to  the  existence  of  a  for- 
eign growth,  the  diagnosis  must  be  made  from  the  gen- 
eral symptoms  s.ud/>er  viani  exclusionis.  The  resemblance 
in  symptomatology  between  stone  and  vesical  growths  is 
such  that  in  a  large  proportion  of  cases  the  patients  were 
sounded  for  calculus.  But  while  irritable  bladder,  hcema- 
turia,  and  pain  are  prominent  symptoms,  common  to  both 
affections,  they  behave  in  a  manner  characteristic  of  each. 

In  stone,  irritable  bladder  is  an  earlj-and  constant  symp- 
tom ;  the  heematuria  is  a  later  manifestation  ;  the  hemor- 
rhage appears  after  exercise,  and  disappears  with  rest,  and 
the  quantity  of  blood  in  the  urine  is  usually  small.  Pain 
is  particularly  felt  with  movement,  with  jolting,  and  after 
micturition,  and  disappears  with  rest  in  the  horizontal 
position.  The  urine  also  soon  contains  mucus  and  pus. 
With  tumor,  irritable  bladder  is  a  later  manifestation,  and 
is  sometimes  entirely  absent.  H^ematuria  usualh^  appears 
early  ;  it  is  often  the  first  and  only  symptom  throughout. 
It  occurs  independent  of  movement,  and  is  often  profuse  ; 
even  while  at  rest  in  bed.  Pain  is  not  occasioned  or  ag- 
gravated by  movement  or  position  ;  but  sensitiveness  of 
the  urethra  and  pain  at  the  glans  penis  is  perhaps  more 
severe  than  in  stone  ;  while  the  urine,  during  the  intervals 
of  hemorrhage,  may  be  perfectly  clear  and  free  from  any 
sign  of  disease.  Pediculated  growths  often  produce  a  sud- 
den stoppage  in  the  fiow  of  urine,  as  is  also  observed  in 
calculus  ;  it  may  be  that  the  tumor  has  engaged  in  the 
vesical  orifice,  or  that  the  urethra  has  become  obstructed 


5o  TUMORS   OF   THE   BLADDER. 

by  a  clot  of  blood,  which  being  passed  with  some  strain- 
ing, the  urine  again  flows  freely. 

The  spongy  texture  of  certain  tumors,  especially  villous 
growths,  affords  an  attractive  surface  for  the  deposition  of 
phosphatic  salts,  which  concretions,  imparting  the  sensa- 
tion of  grittiness,  and  at  times  even  giving  the  click  of  a 
calculus,  have  deceived  surgeons  into  the  belief  of  the  pres- 
ence of  a  stone.  If  the  incrusted  tumor  is  movable,  such 
a  mistake  is  still  more  easily  made. 

Duration  and  Prognosis. 

The  duration  of  life,  after  a  tumor  has  once  commenced 
to  develop,  depends  upon  the  nature  of  the  growth.  The 
two  principal  sources  of  danger  to  life,  in  non-malignant 
tumors,  is  from  the  loss  of  blood,  and  from  the  effects  of 
mechanical  obstruction  to  the  outflow  of  urine.  When 
death  is  not  caused  by  hsematuria,  the  autopsy  always 
reveals  extensive  anatomico-pathological  changes  in  the 
urinary  tract.  Situated,  as  these  growths  so  often  are, 
over  the  opening  of  the  ureters  or  at  the  vesical  neck,  that 
is,  at  the  outlets  of  the  kidneys  and  bladder  respectively, 
they  cannot  fail  to  act  obstructively  to  these  channels,  and 
produce,  in  natural  sequence,  hypertrophy  of  the  bladder, 
dilatation  of  ureters,  hydronephrosis,  structural  change 
in  secreting  substance  of  kidney,  uraemia,  and  death.  It 
may,  therefore,  be  said  that,  while  for  simple  tumors  the 
prognosis  is  good,  especially  in  women,  as  the  growths  are 
accessible  and  capable  of  complete  extirpation  ;  if  uninter- 
fered  with,  the  prognosis  is  no  better  than  for  cancer ;  in- 
deed, they  may  prove  even  more  rapidly  fatal  by  their  local 
effects  than  would  ensue  from  constitutional  infection  in 
malignant  disease.  Nevertheless,  there  is  abundant  evi- 
dence that  simple  growths  may  exist  in  the  bladder  for 
many  years,  during  which  the  individual  may  enjoy  con- 
tinued health.  Hudson  relates  a  case  of  a  man  aged  sixty- 
iive,  who,  when  fifty-four  years  of  age,  eleven  years  before 


TUMORS   OT^    THE   BLADDER.  6l 

death,  first  observed  his  urine  to  be  discolored,  and  about 
this  time  had  obstruction  to  flow  of  urine ;  the  bladder 
was  found  to  be  distended  with  blood-clot,  which  was 
broken  down  with  a  catheter  and  removed  by  the  help  of 
Clover's  syringe.  After  the  lapse  of  time,  cystitis  super- 
vened and  blood  used  to  come  away  with  the  urine  in 
large  quantity.  Nitrate  of  silver  injections  were  made 
under  chloroform  at  intervals  for  several  weeks.  After 
this,  he  was  completely  cured  and  continued  in  good 
health  for  nearly  eight  years.  In  1875,  he  again  had  blood 
in  his  urine  at  intervals  of  three  or  four  days.  Pain  and 
frequent  micturition  were  his  most  prominent  causes  of 
complaint.  Clots  were  rarely  seen  in  the  urine.  For 
three  months  previous  to  death,  the  hsematuria  had  en- 
tirely ceased,  portions  of  phosphatic  deposit  were  occa- 
sionally voided,  appetite  was  fair,  a  suppository  required 
only  every  third  night,  and  to  all  appearances  he  was 
gradually  improving,  when  he  died  suddenly,  probably 
from  disease  of  the  heart.  (Plate  i.  shows  the  bladder 
with  its  contained  growths.) 

Mr.  Humphrey  relates  a  case  in  which  there  had  been 
recurring  hemorrhage  for  a  period  of  seven  or  eight 
years.  During  intervals  of  months,  and  once  a  year,  the 
urine  was  quite  clear  and  the  patient  suffered  but  little. 
He  died  after  a  period  of  excessive  hemorrhage.  There 
was  a  pedunculated,  villous  growth  of  the  size  of  a  walnut 
near  the  orifice  of  the  right  ureter,  and  a  smaller  sessile 
growth  of  same  nature  a  short  distance  from  it.  Mr. 
Humphrey  also  mentions  that  in  the  museum  of  St. 
George's  Hospital  is  a  specimen  of  a  solitary  villous 
growth  attached  by  a  narrow  base  to  the  neck  of  the 
bladder,  from  a  gentleman  aged  eighty-one.  The  first 
attack  of  hsematuria,  lasting  eight  months,  was  twenty 
years  before  death.  There  was  no  return  for  four  years, 
after  which  there  were  returns  at  intervals.  In  another 
specimen,  where  the  base  of  the  growth  is  large,  hemor- 


52  TUMORS   OF   THE   BLADDER. 

rhage  occurred  nine  years  before  death ;  there  was  appa- 
rently no  return,  and  no  symptoms  until  two  months 
before  death.  In  another  case  (Specimen  2,006,  College 
Physicians  and  Surgeons,  London),  a  quantity  of  blood  is 
said  to  have  been  passed  sixteen  years  before  death.  No 
return  took  place  till  six  or  seven  years  before  death ; 
then  subsiding,  recurred  after  three  years ;  it  again  sub- 
sided to  recur  two  years  before  death. 

In  malignant  tumors,  however,  the  course  of  the  disease 
is  generally  more  rapid  and  more  certainly  fatal ;  for  now 
there  is  not  only  an  additional  element  to  contend  against 
— the  cancerous  infection,  but  the  local  disease  itself  is 
much  more  serious.  In  addition  to  the  effect  which  can- 
cers have  in  common  with  simple  tumors  to  act  injuriously 
upon  the  urmary  tract  m  opposing  the  free  escape  of 
urine,  the  former  are  prone  to  soften,  ulcerate,  break 
down,  and  setting  up  catarrhal  irritation  in  the  bladder 
and  kidneys,  soon  wear  out  the  strength  and  vitality  of  the 
patient.  In  soft  cancer,  the  duration  of  life  after  the  mani- 
festation of  the  first  symptom  rarely  exceeds  one  or  two 
years.  In  the  case  of  Pollock,  hsematuria  occurred  only 
six  days  defore  death,  though  the  bladder  was  half  filled 
with  a  fungoid  mass.  Other  cases  terminated  fatally  in 
three  four,  five,  eight,  and  nine  months.  Dickinson  dis- 
covered evidence  of  malignant  disease  in  the  urine  m  a 
robust,  vigorous  man,  eight  months  before  death.  Excep- 
tionally, the  disease  may  last  three  or  four  years.  My 
patient,  with  medullary  cancer,  gave  a  history  extending 
over  a  period  of  seventeen  years ! 

In  epithelioma,  the  progress  is  slower.  In  the  case  of 
Hill,  in  which  there  was  quite  extensive  disease,  it  is  said 
that  until  about  four  months  before  death  there  were  no 
symptoms  of  urinary  disease.  But  this  is  a  rare  case  ;  as 
a  rule,  the  disease  lasts  from  one  to  three  years,  and  excep- 
tionally five,  six,  eight,  and  nine  years  (Davies-Colley,Nunn» 
Clark,  Lambl,   Thompson).     The   long   duration  of  some 


TUMORS   OF   THE   BLADDER.  63 

cases  of  vesical  cancer  can  only  be  accounted  for  in  the 
supposition  that  malignant  tumors  are  sometimes  develop- 
ed from  long-,  pre-existing,  benign  growths  which,  having 
remained  for  a  long  time  innocuous,  or  else,  having  already 
occasioned  serious  organic  changes  in  the  urinary  tract, 
require  but  the  cancerous  development  to  run  rapidly  to 
a  fatal  termmation.  My  case  of  medullary  cancer  above 
referred  to,  with  a  history  of  seventeen  years,  renders 
such  a  conclusion  almost  inevitable. 

Treatment. 

Tumors  of  the  bladder  have  been  so  much  looked  upon 
as  a  7iole  me  tajigere,  that  it  may  be  instructive  to  note  what 
has  been  done  and  what  may  be  done  in  this  department 
of  surgery.  The  following  is  a  concise  resume  of  the 
operations  that  have  been  performed  for  the  removal  of 
tumors  from  the  bladder,  up  to  the  present  time.  They 
are  mentioned  m  a  chronological  order  as  regards  females 
and  males  respectively,  and  will  serve  to  show  the  various 
methods  and  manoeuvres  that  have  been  successfully  em- 
ployed. 

Operations  Performed  on   Females. 

1750.  The  first  operation  we  can  find  on  record  for  the 
rem.oval  of  a  tumor  from  the  bladder  was  performed  by 
Warner  in  1750.  The  subject  was  a  woman  aged  twenty- 
three.  On  June  24th,  after  lifting  a  great  weight,  she  was 
seized  with  pain  in  the  back,  and  afterwards,  retention  of 
urine  which  lasted  until  the  29th,  when  she  was  relieved 
by  catheterization.  Nearly  three  years  afterward  she 
appHed  to  Mr.  Warner  and  stated  that  she  had  never  been 
able,  from  the  moment  of  the  accident,  to  void  a  drop  of 
urine  without  the  assistance  of  a  catheter,  and  she  had 
often  lost  blood  in  considerable  quantities.  A  polypus  of 
some  size  projected  into,  and  sometimes  at  the  external 
orifice  of  the  urethra.     An  incision  was  made  in  the  left 


54  TUMORS   OF   THE   BLADDER. 

side  of  the  urethra  about  half  way  to  the  bladder, 
the  mass  drawn  forward  by  a  thread  previously  passed 
through  it,  and  a  ligature  applied  to  its  base  which  was 
very  broad.  On  the  sixth  day  the  tumor,  which  is  given 
as  the  size  of  a  turkey'^  egg,  came  away,  and  the  patient 
recovered  perfectly. 

1823.  In  Howship's  work  on  the  urine,  of  this  date,  a 
case  is  related  of  a  fungous  tumor  of  the  bladder  which  a 
French  surgeon,  M.  Le  Cat,  attempted  to  remove.  He 
cut  into  the  bladder,  and  with  his  forceps  pulled  away  and 
crushed  several  fungi  at  two  different  sittings.  The  wo- 
man died  in  two  days  after  the  second  operation. 

1834.  Pleininger  removed  from  a  female,  aet.  two  and 
three-fourth  years,  a  strawberry-like  mass  which  projected 
into  the  urethra.  The  canal  was  dilated  and  the  mass  re- 
moved by  ligature.  Further  examination  by  rectum  and 
by  sound  revealed  the  presence  of  other  tumors,  but  no 
further  operative  attempt  was  made.  The  child  became 
emaciated  and  finally  died  of  peritonitis.  Autopsy  re- 
vealed numerousflocculent  excrescences  over  the  base  and 
posterior  surface  of  the  viscus  and  also  others  of  a  cartila- 
ginous consistence  and  of  the  size  of  an  almond. 

1844.  Theinemann.  Female,  aet.  forty-five,  a  tumor,  the 
size  of  a  hen's  egg,  with  a  pedicle  one-third  of  an  inch 
thick,  was  followed  into  the  bladder  by  the  urethra  which 
had  already  been  sufficiently  dilated  by  the  tumor,  and  a 
ligature  was  thrown  around  the  pedicle  by  means  of  two 
elastic  catheters  and  then,  with  a  proper  canula,  constricted 
it  as  far  within  the  bladder  as  he  could  reach.  On  the 
third  day,  the  ligature  was  tightened,  and  on  the  sixth  day 
the  polypus  fell  off  and  the  patient  recovered  completely. 
1846.  Guillon  is  said  to  have  removed  from  the  bladder 
of  a  female  a  pediculated  growth  seated  at  the  vesical 
neck,  by  carrying  a  silver  wire  around  it  by  means  of  a 
slightly  bent  catheter. 

1858.  Birkett  applied  a  strong  silk  ligature  around  the 


TUMORS   OF   THE   BLADDER.  65 

root  of  a  polypus  which  protruded  from  the  urethra  of  a 
child  five  years  old.  She  was  very  weak,  and  a  few  days 
after  the  tumor  sloughed,  considerable  pyrexia  supervened, 
and  she  died.  A  number  of  polypi  were  found  in  the  blad- 
der. 

1859.  Senftleben  attempted  the  extirpation  of  a  sarcoma 
through  the  urethra,  which  had  already  been  dilated  by 
the  tumor  large  enough  to  admit  the  index  finger.  An 
attempt  was  made  to  seize  the  base  of  the  tumor  with  for- 
ceps and  draw  it  out;  this,  however,  did  not  succeed,  and 
because  of  the  great  friability  of  the  tumor  it  had  to  be 
removed  piecemeal ;  its  broad  base,  however,  could  not  be 
so  removed.  The  hemorrhage  was  very  insignificant. 
Patient  died  on  the  fourth  day  after  the  operation  from 
purulent  peritonitis.  On  examination  there  was  found  on 
the  right  side  of  the  fundus  a  perforation  large  enough  to 
admit  the  index  finger;  this  was  made  during  the  at- 
tempt at  extirpation. 

1864.  Bryant,  in  the  British  Medical  Journal,  May,  1879, 
says  that,  fifteen  years  before,  he  removed  a  growth  from 
the  bladder  of  a  female  with  the  ecraseur,  and  the  patient 
was  still  quite  well  eight  years  afterwards. 

1864.  Morris,  in  the  same  journal,  refers  to  a  female,  ast. 
fifty-six,  from  whom  he  took  away  a  large  growth  with 
the  ecraseur ;  all  the  immediate  symptoms  were  relieved, 
though  she  died  eventually  of  hydronephrosis. 

1868.  May.  Braxton  Hicks.  Female,  ast.  sixty.  The 
urethra  was  dilated  ;  the  finger  passed,  and  a  caulifiower- 
like  mass,  the  size  of  a  small  orange,  was  found  attached  to 
the  posterior  wall  of  the  bladder,  as  much  of  the  mass  as 
could  with  safety  be  removed  was  taken  away  by  the  for- 
ceps, and  with  the  wire-rope  ecraseur.  This  had  the  effect  of 
restraining  the  bleeding  and  other  symptoms.  Six  months 
afterwards,  however,  the  bladder  became  more  irritable 
and  the  urine  bloody ;  the  urethra  was  again  dilated  and 
S 


56  TUMORS    OF    THE    BLADDER. 

the  tumor  found  not  to  hav^e  recov^ered  its  original  size ;  a 
strong-  solution  of  tannin  was  applied  with  benefit. 

1868.  June.  Guerssant.  Female  child,  set.  twenty- 
two  months.  A  small  tumor,  like  a  nut,  projected  from  the 
urethra,  it  was  seized,/drawn  forwards,  and  a  metallic 
thread  was  passed  as  far  as  possible  round  the  neck  of  it, 
after  gaining  access  to  it  by  dividing  the  urethra  with  the 
scissors.  The  thread  was  gradually  and  slowly  tightened 
by  a  serre-noeud,  but  broke  before  the  tumor  was  separated, 
so  the  operation  had  to  be  finished  by  the  ecraseur.  The 
child  gradually  lost  strength,  and  though  the  bladder 
symptoms  improved,  the  soft  parts  became  inflamed  and 
there  was  sloughing.  Diarrhoea  supervened,  and  she  died 
exhausted  on  the  eighth  day. 

1869.  A.  R.  Jackson.  Female,  set.  iovty.  Fibrous  po- 
lypus. December,  1869.  A  sponge-tent  was  introduced 
and  left  in  four  hours,  after  which,  the  finger  being  intro- 
duced, a  tolerably  dense  mass  with  a  smooth  surface  was 
felt  occupying  the  lower  part  of  the  bladder  and  pressing 
against  and  somewhat  into  the  vesical  orifice  of  the  ure- 
thra. A  larger  tent  was  introduced  and  the  husband  in- 
structed to  remove  it  in  four  hours,  and  should  tumor 
again  appear  to  secure  it  against  return.  On  withdrawal 
of  the  tent,  the  tumor  appeared,  it  was  seized  with  the 
forceps  and  fingers,  but  in  making  traction  it  broke  off  in 
the  urethra.  The  portion  removed  was  a  fleshy-looking 
imass  about  the  thickness  and  nearly  the  length  of  a  finger. 
Two  days  after,  the  tent  was  again  introduced,  the  tumor 
r.appeared  at  the  urethral  orifice,  it  was  grasped  and  drawn 
•out  about  two  inches  and  by  twisting  it  like  a  rope,  a  por- 
tion of  growth  eight  inches  long  and  of  the  thickness  of  the 
ttbumb  was  removed.  Very  little  bleeding  attended  the 
operation.  Several  fragments  came  away  during  four  or 
five  days  succeding.  April  30th,  1870,  patient  fully  regained 
general  health  and  the  incontinence  from  which  she  had 
been  suffering  since  the  operation  was  improving.     (The 


TUMORS    OF    THE    BLADDER.  6/ 

incontinence  was  no  doubt  occasioned  by  the  slow  method 
which  was  adopted  in  dilating  the  urethra.) 

1869.  Simon.  Female,  aet.  seventy;  urethra  dilated, 
finger  discovered  a  pediculated  villous  growth  behind  the 
urethra,  the  most  accessible  portion  of  the  tumor  was 
seized  and  twisted  off  by  forceps,  while  its  infiltrated  base 
was  scooped  out  with  a  sharp  spoon.  The  reaction  was 
insignificant,  although  the  lesion  to  the  vesical  mucous 
membrane  must  have  been  considerable.  Patient  left  the 
bed  on  the  fourth  day  and  remained  perfectly  well  five 
years  afterward. 

1869.  Winckel.  Female,  set.  thirty-nine.  Urethra  di- 
lated with  index  of  left  hand,  near  the  orifice  of  right 
ureter  was  felt  a  large  movable  soft  villous  growth,  small 
pieces  of  which  were  detached  bv  the  movements  of 
the  finger.  After  this,  the  bladder  was  injected  with 
-about  one  hundred  and  fifty  grammes  of  warm  water, 
and  by  means  of  the  finger  and  forceps  all  appreciable 
prominences  were  removed  from  the  posterior  wall  of  the 
bladder.  The  sphincter  contracted  in  such  a  manner  that 
after  withdrawal  of  the  finger  none  of  the  injected  fluid 
escaped.  Patient  made  a  complete  recovery  ;  saw  her  two 
years  after  the  operation  and  there  was  no  sign  of  a  re- 
lapse. 

1872.  C.  S.  Bishop  (related  by  Gross,  Surgery,  second 
edition).  Female,  set.  fifty-six ;  removed  a  cyUndrical 
vascular  polyp  nearly  three  inches  long ;  it  had  a  globalar 
head  eight  lines  in  diameter,  and  was  attached  by  a  narrow 
pedicle  to  the  bas  fond  of  the  bladder.  Finding  a  portion 
of  tumor  projecting  from  meatus,  he  ligated  it.  The  next 
day  applied  a  silver  wire  around  its  neck,  and  at  the  expi- 
ration of  forty-eight  hours  he  removed  the  mass  by  rotat- 
ing a  double  canula  upon  its  axis. 

1874.  Simon.  Female,  ^t.  40  ;  had  urethra  dilated  sev- 
eral times,  and  small  portions  of  tumor  twisted  off  by  for- 
ceps.    Two  vears  after  first  discovery  of  tumor,  patient 


58  TUMORS    OF    THE    BLADDER. 

came  to  Simon,  who,  April  14th,  dilated  the  urethra,  and 
found  that  two-thirds  of  the  bladder  was  occupied  by  a 
tumor.  With  a  sharp  spoon  he  scooped  out  and  removed 
a  large  portion  of  the  growth.  In  the  course  of  about  an 
hour  and  a  half,  the  spopn  was  introduced  into  the  bladder 
about  twenty  times,  and  the  scraping  made  under  the 
guidance  of  the  finger.  Patient  had  only  a  little  pain 
after  the  operation  and  perfect  continence  of  urine.  The 
bladder  was  washed  out  with  luke-warm  water  daily. 
The  urine  soon  acquired  an  acid  reaction,  and  in  five  days 
patient  left  the  bed.  On  April  28th,  the  operation  was 
repeated,  and  again  considerable  portion  of  tumor  re- 
moved. Eight  weeks  after  the  first  operation,  when  the 
patient  left  the  hospital,  there  were  no  papillary  promi- 
nences apparent  to  the  touch,  but  at  the  place  where  the 
tumor  had  been,  there  was  felt  an  uneven,  rather  hard  sur- 
face, covered  with  mucous  membrane.  The  urine  was 
acid ;  the  bladder  pains  had  disappeared ;  could  hold 
water  five  hours,  and  the  general  condition  of  the  patient 
was  excellent.  This  case  is  especially  interesting  as  show- 
ing what  can  be  done  even  with  very  large  and  sessil'^' 
tumors  of  the  bladder. 

1874.  Simon.  Female,  set.  44.  July  ;  urethra  dilated  ;  all 
over  the  internal  surface  of  bladder,  as  far  as  finger  could 
reach,  there  were  warty  or  papillar}'  projections.  A  sharp 
spoon  was  introduced,  and  as  much  as  possible  of  the  new- 
formation  removed.  The  patient  was  quite  well  after  the 
operation,  and  in  the  middle  of  August  the  symptoms  were 
much  better.  But,  he  adds,  the  next  time  she  will  have  to 
submit  to  an  operation  through  the  vesico-vaginal  septum. 

1873  to  1876.  Schatz.  Female,  set.  18.  The  posterior 
three-fourths  of  the  urethra  was  found  dilated  to  the  dia- 
meter of  the  fmger,  by  the  projection  from  the  bladder  of 
a  tumor  the  size  of  a  goose's  egg.  The  tumor  had  its  ori. 
gin  by  a  pedicle  of  about  four  centimetres  in  thickness 
from  the  right  antero-lateral  wall,  one  to  two  centimetres 


TUMORS    OF    THE    BLADDER.  gg 

above   sphincter.     So   much   of  the    tumor   as   could    be 
reached  was  removed  by  the  ecraseur,  and  the  remainder 
separated   in   smaller   portions   by   means   of   the  finger. 
Patient  recovered,  and  had  no  trouble  for  about  a  year. 
In  August,  1874,  she  returned  with  about  the  same  symp- 
toms as  at  first,  and  the  operation  with  the  ecraseur  was 
repeated.     She  was  up  in  a  few  days.     December,   1875, 
gave  birth  to  a  child.     January   loth,  1876,  found  that  the 
tumor  had  not  grown  much  beyond  the  size  of  a  hazel-nut. 
January  20th,  incised  the  right  side  of  the  urethra,  and  in- 
verted the  posterior  wall  of  the  bladder  with  the  tumor 
through  the  urethra  by  means  of  several  threads  previ- 
ously passed  through  the  tumor  from  the  vagina,  and  after 
cutting  out  the  growth  in  two  portions,  united  the  edges 
of  the  wound  with  ten  silk  sutures.     Although  during  the 
operation  the  urethra  was  dilated  to  the  extent  admitting 
two  fingers,  the  patient  retained  her  water  one  hour  after 
the  operation,  and,  afterwards,  two  and  three  hours  ;  from 
the  seventh  day  she  micturated  once  at  night  and  twice 
during  the  day.     There  was  pain  only  on  the  first  day  dur- 
ing micturition.     The  patient  recovered  rapidly.     Micro- 
scopic examination  found  the  tumor  to  be  a  benign  myxo- 
ma. 

1876  to  1878.  Wm.  Alexander.  Female,  set.  44.  The  ure- 
thra was  in  such  relaxed  condition  that  the  finger  could  be 
inserted  into  the  bladder  without  the  infliction  of  much 
pain.  The  floor  of  the  viscus  was  extremely  rough  and 
irregular.  These  irregularities  were  of  various  heights ; 
a  few  were  as  much  as  a  quarter  of  an  inch  from  base  to 
apex,  and  one  seemed  to  be  nearly  an  inch  in  height.  This 
large  one,  on  the  left  side  of  the  bladder,  had  a  rounded, 
enlarged  apex ;  the  apices  of  the  others  were  thin  and 
pointed.  July,  1876,  the  urethra  was  dilated  with  an  anal 
speculum  ;  the  wire  of  an  ecraseur  was  passed  around  the 
Taase  of  the  largest  growth,  and  the  same  cut  through  ;  in 
trying  to  get  it  out,  others  were  displaced  from  their  place 


70  TUMORS   OF    THE   BLADDER. 

of  growth  by  the  movements  of  the  finger,  and  all  nodules 
that  could  be  felt  were  scraped  off  with  the  finger-nail,  and 
the  bladder  washed  out  with  a  weak  solution  of  perchloride 
of  iron.  There  was  not  an  excessive  amount  of  hemor- 
rhage during  the  operatipn,  but  the  urine  contained  a  good- 
deal  of  blood  for  the  first  week.  She  had  incontinence  of 
urine  for  two  days  only,  during  which  scraps  of  the  tumor 
came  away.  There  were  about  two  dozen  small  growths 
removed,  and  five  or  six  growths  were  lost.  The  patient 
soon  resumed  her  work  as  cook  in  a  very  good  condition. 
In  October,  1877,  she  had  a  relapse.  Numerous  soft 
growths  were  felt  upon  and  beyond  the  trigone;  about  a 
dozen  small  arborescent  growths  were  easily  removed  by 
the  finger-nail,  and  several  small  growths  came  away  the 
same  evening.  October  19th,  urine  was  perfectly  clear; 
pain  on  micturition  was  almost  gone  ;  health  was  good,  and 
system  well  nourished.  May,  1878,  agam  removed  a  large 
mass  of  growths.  Recovery  was  more  rapid  and  more 
perfect  than  on  either  of  the  previous  occasions,  and  the 
urine  has  continued  clear  ever  since,  August  17th,  1878. 

1879.  Christopher  Heath.  Female,  a2t.  3-9.  Urethra 
was  dilated  with  a  four-bladed  dilator  and  the  finger. 
Right  side  of  bladder  was  occupied  by  a  villous  growth, 
situated  on  a  hardened  base.  Some  of  the  growth  was 
torn  away  (villous  sarcoma).  Patient  died  May  25th,  from 
general  exhaustion. 

1879.  Godson.  Female,  set.  sixty.  A  polypus  the  size 
of  a  walnut  was  found  protruding  from  the  urethra  and 
connected  with  a  narrow  pedicle  with  the  fundus  of  the 
bladder,  which  viscus  was  partially  inverted.  Catgut  liga- 
ture was  applied  and  the  tumor  separated  with  scissors. 

1879.  Incision  Urethro-Vaginal  Septum.  A.  T.  Norton. 
Female,  ast.  thirty,  January  3d,  1879.  Dilated  urethra  with 
the  finger  and  discovered  a  papilloma,  in  size  about  one 
square  inch  and  coated  with  phosphates,  not  much  raised 
above  the  mucous  surface,  but  very  hard,  and  situated  oa 


TUMORS   OF   THE   BLADDER.  71 

the  trigone  about  half  an  inch  from  the  sphincter.  It  was 
impossible  to  remove  the  growth  through  the  urethra. 
The  spring  scissors  were  inserted, one  blade  into  the  bladder 
nearly  up  to  the  tumor  and  the  other  into  the  vagina,  and 
closed  ;  the  front  wall  of  the  vagina  was  then  incised  cen- 
trall}^  to  within  half  an  inch  of  the  uterus.  The  vagina 
which  was  not  incorporated  in  the  growth  was  dissected 
from  the  bladder,  the  growth  was  seized  with  the  vulsel- 
lum  forceps,  drawn  forwards,  and  excised  with  the  scissors. 
Bleeding  was  arrested  by  the  actual  cautery  and  the  lateral 
flaps  of  the  vagina  were  approximated  by  sutures.  No 
hemorrhage  of  importance  took  place.  The  temperature 
remained  below  normal  and  the  pulse  rose  to  one  hundred 
and  twenty.  Severe  vomiting  was  persistent  until  the 
tenth  day  after  the  operation.  After  the  tenth  day,  she 
was  considered  out  of  danger,  was  making  good  progress, 
took  food  well,  and  was  cheerful.  On  the  twelfth  day, 
when  apparently  in  health,  she  vomited,  and  shortly  after- 
ward fell  asleep,  in  which  sleep  she  died  from  syncope  at 
a  time  when  she  was  recovering  from  the  operation. 

1879.  ^^^-  Norton  says  that  soon  after  the  above  experi- 
ence he  had  an  opportunity  of  operating  a  second  time,  in 
a  similar  manner,  without  any  untoward  symptom.  Tumor 
was  situated  on  the  front  wall  of  the  bladder ;  it  was  one 
inch  long,  one-half  inch  wide,  and  three-quarter  inch  above 
the  level  of  the  mucous  membrane.  It  did  not  infiltrate 
the  tissues  of  the  bladder.  Structure,  fringed  papilloma. 
The  opening  in  the  bladder  was  allowed  to  remain  for  a 
month  and  then  it  was  closed  by  the  ordinary  method. 

Operations  Performed  on  Males. 
1827.  Civiale,  while  manipulating  with  his  trilabe  with 
a  view  of  removing  a  calculus  from  the  bladder,  acciden- 
tally tore  away  a  soft,  pedunculated  mass  about  the  size 
of  a  pea.  This  accident  at  first  gave  him  some  uneasiness 
as   to   the   possible   result ;    but   no   untoward   symptom 


j2  TUMORS   OF   THE   BLADDER. 

appearing,  he  conceived  the  idea  of  having  recourse  to 
this  manoeuvre  for  the  removal  of  small  growths  at  the 
neck  of  the  bladder,  which  he  put  into  successful  practice 
in  several  cases.  In  a  man  aged  seventy,  he  used  the 
trilabe  three  times,  at  intervals  of*some  days,  each  time 
taking  away  a  small  portion  until  he  had  removed  a  mass 
the  size  of  a  large  walnut.  The  man  died  three  months 
afterward  from  typhoid  fever.  The  method  of  operating, 
as  recommended  by  Civiale,  consists  in  opening  the  instru- 
ment in  the  bladder,  drawing  it  forward  as  far  as  possible 
so  that  the  blades  of  the  same  lie  in  contact  with  the  vesi- 
cal neck,  when  by  turning  the  instrument  from  side  to  side 
the  excrescences  fall  between  its  blades  and  are  crushed. 
In  a  few  days  the  necrosed  portion  is  carried  off  with  the 
urine. 

Covillard  (Obs.  latro-chir.  p.  93,  mentioned  by  Crosse) 
performed  cystotomy  for  a  tumor  in  the  bladder  the  size 
of  a  nut.  "  Je  la  mouchait  avec  les  tenettes,  ceque  reussit 
de  sorte  qu'en  moins  de  huit  ou  dix  jours,  la  dite  tumeur 
termin'a  par  suppuration,"  and  in  a  month  the  patient  was 
convalescent. 

1830.  Perineal  Cystotomy.  Dessault.  Chopart  mentions 
a  man  at  the  I'Hotel  Dieu,  from  whom  D.  extracted  a  cal- 
culus, and  afterwards  finding  a  pediculated  growth,  he 
seized  it  and  twisted  it  off.  There  was  no  hemorrhage, 
and  the  patient  left  the  hospital  perfectly  cured. 

1834.  Crosse  performed  perineal  cystotomy  for  the  re- 
moval of  a  villous  growth,  upon  a  male  child  two  years 
old.  On  removing  the  knife  after  the  necessary  incisions 
were  made,  a  mass  of  tumors,  connected  together  like  a 
bunch  of  grapes,  and  resembling  in  appearance  and  struc- 
ture ordinary  nasal  pol3^pi,  protruded  through  the  wound  ; 
as  many  of  these  as  were  accessible  were  cut  off,  but  upon 
introducing  the  finger  into  the  bladder,  it  was  found  that 
much  of  the  diseased  mass  remained  attached  by  a  broad 
base,  and  it  was  not  deemed  advisable  to  make  any  further 


TUMORS   OF   THE   BLADDER.  73 

attempt  for  its  removal.  After  forty-four  hours  of  inces- 
sant suffering,  the  child  died. 

1 87 1.  Gersuny  attempted  to  remove  a  tumor  from  a  man 
aged  forty-nine,  by  perineal  cystotomy,  but  the  growth 
was  beyond  reach  in  a  diverticulum,  and  the  operation 
failed.  The  day  following,  the  patient  felt  better  than  be- 
fore the  operation,  and  afterward  made  no  complaint  of 
any  kind,  but  refusing  all  nourishment,  he  gradually  be- 
came exhausted,  and  died  after  the  sixth  day. 

1874.  Perineal  and  Supra-pubic  Cystotomy.  Billroth. 
Boy,  £et.  twelve.  Lateral  incision  was  made  ;  finger  intro- 
duced into  bladder,  and  a  tumor  found  nearly  the  size  of 
the  fist,  with  an  uneven  surface  projecting  from  the  pos- 
terior wall  and  extending  towards  the  top  of  the  bladder. 
Owing  to  its  size,  it  was  impossible  to  extract  tumor 
through  the  perinseum.  A  supra-pubic  incision  Avas  made 
without  injury  to  peritonseum,  and  to  give  sufficient  room 
both  recti  muscles  were  cut  across  at  their  insertion  ;  a 
transverse  incision  was  also  made  into  the  Bladder.  Bill- 
roth found  that  the  use  of  the  ecraseur  was  not  practica- 
ble, and  decided  to  tear  the  tumor  with  his  finger-nail 
near  its  base,  and  to  cut  out  the  remainder  from  the  wall 
of  the  bladder,  after  passing  a  ligature  around  to  check 
the  bleeding.  In  dissecting  out  the  pedicle,  it  was  found 
that  the  tumor  took  its  origin  from  the  muscular  coat. 
Two  arteries  were  tied,  and  the  ligatures  brought  out 
through  the  upper  incision.  The  wound  in  the  bladder 
was  not  closed,  but  a  drainage  tube  was  drawn  through 
the  bladder  and  brought  out  at  the  perineal  incision.  On 
the  fifth  day,  the  wound  -was  granulating  freely,  and  there 
being  no  more  danger  of  infiltration,  the  drainage-tube 
was  removed.  In  thirty-four  days,  the  wound  had  closed, 
and  the  patient  was  discharged  cured.  Tumor  is  seen  at 
Plate  ix. 

1874.  Perineal  and  Epicystotomy.  Volkmann.  Male,  set. 
fifty-four.     Membranous  urethra  was  opened  on  the  raphe 


y.  TUMORS   OF    THE   BLADDER. 

of  the  perineum,  and  the  finger  passed  into  the  bladder.  A 
tumor  was  found,  of  the  consistence  of  a  uterine  polypus, 
and  about  the  size  of  a  lemon,  attached  by  a  pedicle  to 
vertex  of  bladder.  Epicystotomy  was  now  made,  the 
bladder  being  opened  by  incision  one  and  one-quarter 
to  one  and  one-half  inches  long,  made  on  the  finger,  passed 
through  the  perineal  wound.  Peritonseum  not  visible  ; 
the  tumor  appeared  at  once,  its  surface  covered  with 
dilated  veins,  and  on  scratching  through  the  pedicle,  which 
was  of  the  size  of  the  little  finger,  the  growth  was  removed 
by  traction  with  forceps,  assisted  by  pressure  from  the 
rectum.  The  wound  in  the  bladder  and  abdominal  walls, 
after  washing  with  carbolized  water,  were  closed  with  su- 
tures;  the  whole  abdomen  enveloped  in  carbolized  gauze, 
and  a  drainage-tube  placed  in  the  perineal  wound.  The 
following  day,  abdomen  became  tender  ;  peritonitis  devel- 
oped, and  death  ensued  on  the  third  day  after  operation. 
Autopsy  revealed  peritonitis,  diffuse  purulent  infiltration 
of  subserous  areolar  tissue  of  abdominal  wall ;  muscular 
coat  of  bladder  moderately  hypertrophied  ;  mucous  mem- 
brane swollen,  showing  a  number  of  old  and  recent  ecchy- 
moses,  but  otherwise  healthy.  At  the  situation  of  the 
pedicle,  which  is  four  lines  long,  the  muscular  coat  is 
exposed  on  the  posterior  wall.  Volkmann  beheves  the 
extravasations  of  blood  to  have  been  caused  by  the  rectal 
explorations.  No  sign  of  inflammation  about  the  inci- 
sions. The  size  and  form  of  the  tumor  is  represented  at 
Plate  X. 

1874.  Kocher.  Male,  ast.  thirty-four.  Began  to  suffer 
in  the  spring  of  1874,  with  a  constant  desire  to  micturate 
and  incontinence.  In  June,  these  symptoms  changed  to  a 
violent  burning  pain  and  increased  desire  to  pass  water. 
Urine  of  intolerable  odor,  and  contains  blood  and  pus. 
A  piece  of  tumor  which  came  out  proved  to  be  a  papillary 
growth.  December  31st,  urethra  was  opened  by  a  T- 
shaped  incision.     A  vertical  cut  in  the  mesial  line  and  a 


TUMORS    OF    THE    BLADDER.  j  c 

horizontal  one,  after  Nelaton's  pre-rectal  method.  The 
urethra  was  opened  on  a  grooved  staff  and  the  finger 
introduced  into  the  bladder.  On  its  posterior  wall  was  felt 
the  soft,  tufted,  fungoid  mass  of  the  new-growth  ;  a  large 
sharp  scoop,  bent  at  an  angle,  was  introduced  against  the 
finger,  whereby  it  was  forcibly  scraped  off.  The  hemor- 
rhage was  pre  tty  severe,  but  was  arrested  by  cold  water 
injections.  No  dressing  was  applied.  The  wound  healed 
in  six  weeks,  and  in  fifteen  months  the  patient  was  consid 
ered  as  quite  cured. 

1877.  Humphry.  Male,  ast.  twenty -one.  A  mass  could 
be  felt  in  the  bladder  above  and  behind  the  pubes.  Suf. 
fering  being  extreme,  made  an  incision  into  the  bladder  as 
for  lateral  lithotomy,  and  found  a  firmish  tumor,  with  a 
ragged  surface,  attached  by  a  pedicle  to  near  the  orifice  of 
right  ureter.  Partly  by  finger  and  partly  by  forceps,  the 
pedicle  was  torn  through,  and  the  tumor  was  extracted 
with  lithotomy  forceps.  The  root  of  the  pedicle  was 
scraped  out  with  the  finger-nail.  After  a  day  of  compar- 
ative ease,  the  pain  returned  with  great  severity,  requiring 
the  subcutaneous  injections  of  morphia,  which  had  to  be 
increased  to  large  doses,  and  continued  for  more  than  two 
months.  Then  the  pain  diminished  and  gradually  sub- 
sided. The  wound  healed,  and  the  patient  completely 
recovered,  and  was  quite  well  eighteen  months  after  the 
operation. 

1880.  Davies-CoUey.  Male,  2et.  thirty-two.  Opened 
the  bladder  by  the  usual  incision  for  lateral  lithotomy. 
At  first  nothing  could  be  felt.  Then  a  slight  projection 
was  made  out  on  the  left  side  of  the  fundus,  and  a  cord- 
like process  running  from  it.  In  a  short  time  the  free  end 
of  this  process,  with  a  soft  pinkish  tuft  of  villi  attached  to 
it,  was  seen  at  the  deeper  part  of  the  wound.  This  was 
seized  with  the  forceps,  drawn  out,  and  the  pedicle  cut 
with  a  pair  of  scissors  close  to  the  wall  of  the  bladder. 
No  other  growth    could   be  felt.     There    was   but   little 


y5  TUMORS   OF   THE   BLADDER. 

hemorrhage  during-  the  operation,  and  some  which  oc- 
curred in  the  evening  was  readily  arrested  by  the  injection 
of  iced  water  into  the  bladder.  He  made  a  rapid  recov- 
ery. In  two  weeks,  the  urine  ceased  to  flow  from  the  pe- 
rinceum,  and  soon  after>vards  the  wound  healed.  When 
last  seen,  two  months  after  the  operation,  there  had  been 
no  return  of  the  hemorrhage.  The  irritability  of  the  blad- 
der had  ceased,  and  he  was  in  the  enjoyment  of  perfect 
health.  The  tumor  grew  from  the  posterior  wall  of  the 
bladder,  at  a  point  about  three  inches  from  its  neck, 
and  one  inch  to  the  left  of  the  middle  line.  It  consisted 
of  a  fibrous  stalk,  one-sixth  of  an  inch  thick  and  two  inches 
long,  and  terminated  by  branching  filaments  from  half  an 
inch  to  three-quarters  of  an  inch  long.  These  filaments 
contained  capillary  loops,  invested  by  many  layers  of 
epithelium  of  a  cylindrical  shape. 

1880.  Supra-pubic  Cystotomy.  Marcacci.  Male,  set. 
fifty-four.  An  incision  thirteen  centimetres  in  length  was 
made,  commencing  one  centimetre  above  the  upper  mar- 
gin of  the  symphysis  pubis,  and  extending  through  the 
linea  alba.  The  bladder  was  found  to  be  enormously  dis- 
tended, its  whole  interior  being  filled  with  a  large  neoplas- 
tic mass ;  this  was  removed.  The  wound  in  the  bladder 
was  brought  together  with  four  catgut  sutures ;  that  in 
the  abdomen  with  interrupted  metallic  sutures,  and  the 
whole  dressed  antiseptically.  The  patient  progressed 
favorably  during  the  first  ten  days,  when,  on  the  removal 
of  the  metallic  sutures,  the  wound  being  apparently  healed, 
a  few  drops  of  urine  escaped  from  the  openings  where  the 
sutures  had  been.  All  attempts  to  cure  these  urinary  fis- 
tulce  failed.  Patient  died  within  two  months  after  the 
operation  from  extravasation  of  urine,  pelvic  abscess,  and 
peritonitis.  M.  considers  that  the  cause  of  death  was  due 
to  the  too  early  absorption  and  destruction  of  the  catgut 
sutures,  which  probably  lost  their  holding  power  before 
the  wound  in  the  bladder  had  become  consolidated. 


TUMORS   OF   THE   BLADDER. 


n 


1880.  Berkeley  Hill.  Male,  set.  sixty-three.  Not  with 
any  expectation  of  effecting-  a  cure,  but  of  affording  relief, 
the  lateral  incision  as  for  stone  was  made,  the  finger 
introduced,  and  a  soft  mass,  about  as  large  as  a  marble, 
projecting  from  the  floor  of  the  bladder  on  the  right  side, 
was  brought  away  in  a  lithotomy  forceps.  By  free  injec- 
tions of  cold  water,  several  such  masses  were  washed  out 
along  with  much  stinking  pus  and  mucus.  The  patient 
was  but  little  relieved  by  the  operation,  and  death  oc- 
curred on  the  third  day  from  exhaustion,  consequent  on 
the  irritation  of  bladder  and  from  cachexia  of  a  malignant 
tumor,  which  was  found  in  the  bladder  after  death. 

Perhaps  not  altogether  irrevelant  to  the  operations 
above  recorded  is  one  performed  by  Liston  (related  by 
Robt.  Knox,  M.D.,  Lon.  Med.  Times  anei  Gaz.,  August  2d, 
1862),  for  the  removal  of  a  cyst  from  the  bladder  of  a  man 
suffering  with  difficulty  in  discharging  his  urine.  Liston 
passed  a  catheter  and  felt  a  soft,  yielding  but  obstructing . 
body  in  the  prostatic  portion  of  the  urethra.  This  readily 
gave  way  before  the  catheter,  which  then  passed  into  the 
bladder,  but  on  being  withdrawn  it  was  followed  by  the 
foreign  body,  which  immediately  reoccupied  its  former 
position.  Liston  opened  the  bladder  above  the  pubes, 
and  as  the  incision  was  made,  there  escaped  from  the 
bladder  a  body  resembling  a  cyst  or  false  membrane  of 
the  shape  of  the  interior  of  the  bladder.  The  wound  was 
closed,  the  patient  recovered  and  lived  for  some  time. 

From  the  foregoing  we  learn  that  thirty-four  operations 
have  been  performed  for  the  removal  of  tumors  from  the 
bladder :  twenty-three  upon  females  and  eleven  upon 
males. 

In  seventeen  of  the  former,  the  growths  were  removed 
through  the  urethra  by  previous  bloodless  dilatation  of 
the  canal,  and  in  six  by  incision  of  the  urethra  or  of  the 
vesico-vaginal  septum.  The  subjects  varied  in  age  from 
twenty-two  months,  two  and  three-quarter  and  five  years 


78  TUMORS   OF    THE    BLADDER. 

to  seventy  years.  The  growths  removed  have  included 
papillomata,  myxomata,  myomata,  and  sarcomata.  The 
tumors  have  been  removed  by  simple  torsion  and  avulsion, 
by  ligature,  silk,  and  catgut,  silver  wire,  bv  ecraseur  and 
by  scooping,  out  with  a  sharp  spoon.  Excepting  the  method 
of  scooping,  in  which  the  hemorrhage  is  sometimes  consid- 
erable, the  loss  of  blood  in  the  other  operations  was  insigni- 
ficant. Of  the  seventeen  patients  from  whom  the  growths 
were  removed  by  urethral  dilatation,  ten  recovered.  In 
this  number  we  include  the  cases  of  Guillen,  Bishop,  and 
Godson,  in  which,  although  the  result  is  not  absolutely 
stated,  the  phraseology  is  such  that  there  can  be  little 
doubt  as  to  their  successful  termination.  Two  cases  are 
reported  as  much  improved  bv  the  operation  and  five  ter- 
minated fatally.  After  the  six  cutting  operations,  three  re- 
covered and  three  died.  We  thus  find,  after  both  opera- 
tions, a  total  of  thirteen  recovered,  two  improved  and  eight 
died. 

Let  us  now  examine  to  what  degree,  in  the  fatal  cases, 
the  operations  may  be  regarded  as  having  been  the  imme- 
diate cause  of  death.  In  the  patient  of  Le  Cat  we  have  no 
data  other  than  that  she  died  in  two  days  after  the  second 
operation.  In  Heath's  case,  a  portion  of  sarcoma  was  torn 
away  and  the  patient  died  a  month  after,  from  general  ex- 
haustion. In  the  case  of  Morris,  the  patient  improved  by 
the  operation,  but  died  eventually,  he  does  not  say  when, 
evidently  at  some  remote  period,  from  hydronephrosis. 
In  Guerssant's  child,  aged  twentj^-two  months,  the  bladder 
symptoms  improved,  but  the  child  weakened,  had  diarrhoea, 
and  died  exhausted  on  the  eighth  day.  Norton's  patient 
died  on  the  twelfth  day  when  apparently  in  health  ;  she 
vomited,  and  shortly  afterwards  fell  asleep  in  which  sleep 
she  died  from  syncope  at  the  time  when  she  was  recover- 
ing from  the  operation. 

In  these  four  cases,  certainly  it  cannot  be  said  that  the 
operation    caused   or  precipitated  the   fatal   termination. 


TUMORS    OF    THE    BLADDER.  p^g 

Neither  is  this  at  all  evident  in  the  patients  of  Pleininger 
and  Birkett ;  both  of  those  were  children,  aged  respectively 
two  and  three-quarters  and  five  years.  The  first  little  suf- 
ferer remained  unrelieved  by  the  operation,  because  nu- 
merous growths  were  left  behind.  "  She  became  emaciated 
and  finally  died  of  peritonitis."  It  does  not  appear  how 
soon  after  the  operation  death  ensued,  but  from  the  lan- 
guage we  may  reasonably  infer  that  the  peritonitis  had  no 
connection  with  the  operation.  The  other  patient  was  a 
very  weakly  child,  and  a  few  days  after  the  tumor  came 
away,  considerable  pyrexia  supervened  and  she  died.  It 
may,  therefore,  be  said  that  in  but  one  of  the  eight  fatal 
cases  in  the  female  can  the  operation  be  positively  held  as 
the  immediate  cause  of  death.  In  this  case  (Senftleben), 
the  bladder  was  perforated  during  the  attempted  removal 
of  a  sarcoma,  and  the  patient  died  on  the  fourth  day  from 
purulent  peritonitis. 

With  regard  to  the  size  and  character  of  the  growths 
that  may  be  successfully  removed  through  the  urethra, 
some  are  given  as  the  size  of  a  goose's  egg,  turkey's  egg, 
etc.,  which  have  been  removed  by  ligature,  ecraseur,  etc. 
But  the  most  noteworthy  operation,  as  showing  what  can 
be  done  even  in  the  least  promising  of  cases,  is  that  of 
Simon,  who  successfully  scooped  out  from  the  walls  of  the 
bladder  a  sessile  tumor  that  had  occupied  two-thirds  of 
the  cavity  of  that  viscus. 

The  male  bladder  has  been  opened  for  the  removal  of 
tumors  eleven  times :  eight  times  through  the  perinasum, 
including  in  this  enumeration  Covillard's  operation,  about 
the  precise  nature  of  which,  however,  we  have  no  data ; 
twice  jointly  through  the  peringeum  and  above  the  pubes, 
and  once  above  the  pubes  only  (not  including  Liston's 
successful  removal  of  a  cyst).  Of  these  eleven  opera- 
tions, six  proved  successful  and  five  fatal.  Of  the  success- 
ful cases,  five  recovered  after  perineal  cystotomy  and  one 
after  both  perineal   and  supra-pubic  cystotomy.     Of  the 


3o  TUMORS   OF   THE   BLADDER. 

deaths,  three  occurred  after  perineal  cystotomy,  one  after 
both  perineal  and  supra-pubic  cystotomy,  and  one  after 
supra-pubic  cystotomy.  The  ages  of  the  subjects  operated 
upon  varied  from  two  to  sixty-three  years. 

These  statistics  would  show  apparently  a  mortality  of 
nearly  fifty  per  cent,  but  a  more  careful  examination  will 
show  that  such  a  percentage  of  deaths  is  probably  much 
in  excess  of  what  may  be  expected.  In  the  first  place,  the 
case  of  Hill  cannot  be  included  in  the  results,  as  militating 
against  the  operation,  for  this  was  not  done  with  any  idea 
of  effecting  a  cure,  but  simply  as  a  palliative  measure, 
with  the  hope  of  affording  temporary  relief  from  intense 
suffering  due  to  malignant  disease  in  a  subject  sixty-three 
years  old,  alreadv  worn  out  and  cachectic.  The  case  of 
Gersuny  was  very  exceptional  in  that  the  tumor  was 
inclosed  in  a  diverticulum  of  the  bladder  and  was  alto- 
gether bej'ond  reach.  Besides,  the  tumor  had  been  of  so 
long  standing  that  it  had  given  rise  to  other  serious  changes 
in  the  vesical  walls,  which,  even  m  the  event  of  the  suc- 
cessful removal  of  the  tumor,  would  have  rendered  recov- 
er}"  impossible  (see  Plate  iv.,  Fig.  i).  In  the  child  of  Crosse, 
the  growths  were  but  partially  removed,  hence  recovery 
could  not  have  been  expected.  In  the  cases  of  Volkmann 
and  Marcacci,  the  cause  of  death  was  the  imperfect  closure 
of  the  vesical  wound.  In  both,  the  w^ound  in  the  bladder 
and  abdomen  was  closed  with  sutures.  In  the  first  case, 
death  occurred  on  the  third  day  from  peritonitis  and  dif- 
fuse purulent  infiltration  of  subserous  areolar  tissue.  In 
the  latter,  the  vesical  wound  was  brought  together  with 
catgut  ligatures,  and  the  abdominal  wound  with  metallic 
sutures.  Patient  did  well  at  first,  but  died  within  two 
mionths  from  extravasation  of  urine,  pelvic  abscess  and 
peritonitis,  because,  as  Marcacci  thinks,  of  the  too  early 
absorption  and  destruction  of  the  catgut  sutures,  which 
probably  lost  their  holding  power  before  the  union  of  the 
wound  in  the  bladder  had  become  firmly  established.  The 


TUMORS   OF   THE   BLADDER.  gl 

question  might  here  be  asked,  if,  when  the  imperfect 
closure  of  the  bladder  was  first  manifest  by  the  appearance 
of  the  supra-pubic  urinary  fistula,  the  fatal  complications 
might  not  have  been  averted  had  the  bladder  been 
opened  in  perinseum. 

In  this  connection,  it  may  also  be  noted  that  a 
number  of  post-mortem  examinations  indicate  that  the 
cases  of  successful  removal  of  tumors  from  the  bladder 
might  have  been  multiplied  by  an  early  operation.  In 
some  cases,  the  bladder  has  been  actually  opened  and 
yet  no  attempts  were  made  for  the  removal  of  an  existing 
tumor.  Perhaps  the  earliest  example  of  this  is  recorded 
of  Petit,  of  whom  it  is  said  that,  although  he  did  not  re, 
move  the  polypus,  the  operation  of  opening  the  bladder 
was  not  attended  with  any  bad  result,  and  a  year  after- 
wards, on  post-mortem  examination,  it  was  discovered  that 
there  was  a  polypus  the  size  of  a  fist  in  the  bladder,  of  a 
pyramidal  figure  and  attached  by  a  very  delicate  pedicle. 
Although  this  man,  aged  twenty-eight,  is  said  to  have  died 
of  phthisis,  there  is  probably  little  doubt  that  his  life  would 
have  been  prolonged  by  the  removal  of  the  growth  which 
apparently  could  have  been  most  easily  accomplished. 
Gross  alludes  to  two  operations  for  stone,  one  Deschamp's, 
the  other  his  own,  in  which  the  calculi  were  extracted,  but 
the  neoplasms  which  were  afterwards  found  were  not  in- 
terfered with.  He  does  not  say  why,  but  speaks  of  his 
own  case  as  a  tumor  situated  on  the  anterior  wall  of  the 
bladder,  lobulated  and  sessile.  From  a  reference  to  the 
histories  and  drawings  given  of  several  of  our  cases,  such  as 
those  of  Springall,  Barton  and  Hudson,  in  which  for  some 
reasons  no  operation  was  attempted,  it  will  be  seen  that 
the  removal  of  the  growths  could  have  been  most  easily 
accomplished,  and,  as  it  would  seem,  with  every  prospect 
of  success. 

The  foregoing  citation  of  the  various  methods  adopted 
for    the    removal   of    tumors   from    the    bladder   leaves 
6 


82 


TUMORS   OF   THE   BLADDER. 


little  more  to  be  said  in  regard  to  treatment.  The 
choice  of  an  operation,  however,  will  depend  upon  the 
seat,  nature,  and  size  of  the  growth.  In  the  female,  owing 
to  the  shortness  and  dilatability  of  the  urethra,  tumors 

may  be  removed  by  this  channel 
with  comparative  ease  and  safety. 
The  urethra  being  dilated  in  the 
manner  already  laid  down,  the  left 
index  introduced  and  the  tumor 
recognized,  a  long,  slender  pair  of 
forceps  or  scissors  may  be  guided 
along  the  finger  to  the  pedicle  of 
the  growth,  and  the  same  twisted 
off  or  cut  away.  Fig.  i  represents 
the  forceps  used  by  Simon  for  this 
purpose.  They  are  very  long, 
S-shaped  (A),  and  their  branches 
are  scissors-like,  either  toothed  (^), 
or  with  a  smooth  edge  (c).  If  the 
tumor  is  not  removed  in  this  way, 
it  may  be  treated  by  ecrasement, 
or  ligature,  as  may  be  deemed 
most  expedient.  Sessile  or  flat 
growths  may  be  extirpated  by  the 
knife,  or  by  means  of  sharp  spoons 
especially  constructed  for  the  pur- 
pose. The  instrument  so  success- 
fully employed  by  Simon  is  de- 
picted at  Fig.  2.  It  is  long 
j'iG.  I.       Fig.  2.  handled;  A,  the  edge,  is  very  sharp, 

and  the  spoon  is  bent  at  a  right 
angle  to  the  handle,  <5  and  c.  The  growth  is  scraped  or  cut 
away  by  pressing  the  part  to  be  taken  off  against  the 
edge  of  the  spoon  with  the  finger.  This  operation  is 
always  attended  with  prett}'  free  hemorrhage ;  but  this 
maybe  kept  under  control  by  means  of  iced  water,  injected 


TUMORS    OF    THE    BLADDER.  83 

into  the  bladder,  or  the  application  of  a  pledget  of  lint 
soaked  in  perchloride  of  iron  to  the  base  of  the  tumor, 
and  the  bladder  afterwards  washed. 

If  the  tumor  is  not  accessible,  or  is  too  large  to  admit  of 
removal  after  bloodless  dilatation  of  the  urethra,  the  canal 
may  be  further  enlarged  and  shortened  by  incision.  This 
was  done  successfully,  as  we  have  seen,  by  Warner,  who 
divided  the  left  wall  of  the  urethra  half-way  to  the  blad- 
der, and  also  by  Schatz,  who  incised  the  right  side  of  the 
urethra  and  inverted  the  posterior  wall  of  the  bladder 
with  the  tumor  through  the  urethra  by  means  of  several 
threads  previously  passed  through  the  tumor  from  the 
vagina. 

If  lateral  incision  of  the  urethra  is  not  made,  the  tumor 
may  be  reached  by  kolpo-cystotomy.  In  regard  to  this 
operation,  Simon  recommends  that  the  incision  through 
the  vagino-vesical  septum  should  be  T-shaped.  He  says 
that  by  a  long  incision  through  the  whole  length  of  the 
urethra  to  the  mouth  of  the  uterus  the  bladder  cannot  at 
all,  or  but  very  little  be  introverted.  The  inversion  of  the 
vertex  and  the  upper  part  of  the  fundus,  however,  is 
obtained  after  a  transverse  incision  of  three  centimetres 
in  length  into  the  anterior  wall  of  the  vagina,  one-quarter 
to  one-half  centimetres  in  front  of  the  anterior  lip  of  the 
OS  uteri;  and,  still  better,  when,  besides  the  transverse 
incision,  a  second  one  is  made  at  right  angles  directly 
toward  the  urethra,  so  that  a  T-shaped  incision  results. 
By  the  exercise  of  some  traction  in  the  direction  of  the 
vagina  with  a  fine  double  hook  inserted  into  the  mucous 
lining  of  the  bladder,  and  a  simultaneous  pressure  over 
the  hypogastrium,  the  interior  of  the  bladder  is  made  so 
completely  accessible  by  inversion,  that  the  most  compli- 
cated and  most  difficult  operation  can  be  performed  with 
the  same  facility  as  on  the  surface  of  the  body.  The 
tumors  may  be  extirpated  with  scissors,  knife,  and  even 
the  galvano-cautery  can  be  used.   After  the  internal  wound 


34  TUMORS    OF    THE    BLADDER. 

has  cicatrized,  the  vesico-vaginal  incision  may  be  closed 
by  the  usual  method. 

In  the  male,  the  tumor  ma}'  be  reached  either  through 
the  peringeum  or  from  above   the   pubic    symphysis.     It 
would  scarcely  be  to4:he  purpose  now  to  institute  a  close 
inquiry  into  the  relative   advantages  and  disadvantages 
respectively  of  suprapubic  and  perineal  cystotomy.     For 
the  removal  of  tumors  of  the  bladder,  the  selection  of  an 
operation  can  rarely  be  a  matter  of  choice,  but  must  depend 
upon  the  location,  mode  of  attachment,  and  size  of  the 
growth.     The  perineal  operation  will,  perhaps,  be  more 
frequently  adopted;    i,  because  of  the  usual  seat  of  tu- 
mors in  the  lower  portion  of  the  bladder,  which,  in  the 
absence  of  great  hypertrophy  of  the   prostate,  are   gen- 
erally sufficiently  accessible   from    this   point,  and,  espe- 
cially  if    pediculated,    are    easily    enough    removed  ;    2, 
because  the  operation  itself  is  considered  less  hazardous 
than    is    the    opening    of    the    bladder   from    above ;    3, 
because,  if  after  perineal  cystotomy  the  tumor  proves  to 
be  inaccessible  or  too  large  to  be  thus  removed,  and  supra- 
pubic cystotomy  is  found  necessary  to  reach  it,  the  peri- 
neal incision  will   not   diminish,  but  rather  increase   the 
chances  of  recovery,  by  affording  free   drainage  for  the 
urine  in  the  most  depending  position.     It  is  said  of  Frere 
Come  (i  758-1 778),  whose  high  operations  for  stone  were 
so  successful  that,   in   order  to  prevent   urinary  infiltra- 
tion, he  was   in   the   habit,  before  performing   epicystot- 
omy,  of  opening  the  urethra  in  perinseum.     The  value  of 
perineal  drainage  was  also  appreciated  by  Civiale,  who, 
according  to   Bransby    Cooper  (Coulson,   p.   476),  while 
engaged  in  the   high   operation   for  stone,   accidentally 
wounded  the   peritonseum,  and  fearing  extravasation  of 
urine  into    the    peritoneal   cavit}',   opened    the    bladder 
through  the  perinseum,  and  the   patient   recovered.     In 
Billroth's  case,  the  preliminary  perineal   incision  proved 
eminently  satisfactory. 


TUMORS    OF    THE    BLADDER.  85 

Sometimes,  however,  the  most  available  method  of  reach- 
ing the  tumor  will  be  from  above  the  pubes.  In  addition 
to  the  freedom  from  hemorrhage,  absence  of  danger  of 
wounding  the  rectum  and  ejaculator}^  ducts,  etc.,  statistics 
show  that  for  calculi  above  two  ounces  in  weight  the 
results  after  the  high  operation  are  m.ore  favorable  than 
after  lateral  lithotomy — a  fact  which  has  an  important 
practical  bearing  on  the  possibilities  of  success  in  the 
removal  of  tumors  by  the  supra-pubic  method.  But 
without  further  dwelling  upon  the  relative  advantages  of 
the  two  operations,  the  fact,  that  in  the  high  operation  the 
parts  are  freely  exposed  to  view,  is  an  advantage  which 
must,  in  certain  difficult  cases,  supersede  every  other  con- 
sideration. 

Preparatory  to  the  operation,  the  supra-pubic  region  is 
to  be  shaved,  the  bladder,  after  being  evacuated  of  urine, 
is  distended  with,  perhaps,  a  one-quarter  per  cent  solution 
of  carbolic  acid,  and  if  necessary  or  desirable,  the  bladder 
may  be  still  further  raised  above  the  pubes  by  distending 
the  rectum  with  a  colpeurynter  or  a  few  sponges.  The 
patient  is  placed  in  the  recumbent  posture,  with  the  pelvis 
elevated  above  the  level  of  the  loins  and  shoulders,  so 
that  the  abdominal  viscera  shall  gravitate  away  from  the 
bladder.  The  surgeon,  standing  to  the  left  of  the  patient, 
makes  an  incision  from  three  to  four  inches  in  length,  com- 
mencing immediately  over  the  pubes,  upwards  in  the 
mesial  line  and  down  to  the  aponeurosis  of  the  abdominal 
muscles.  The  linea  alba  being  exposed,  this  structure  is 
divided  at  the  upper  border  of  the  pubes,  sufficiently 
to  admit  a  grooved  director  upon  which  the  linea  alba  and 
fascia  transversalis  are  slit  up  to  the  requisite  extent,  per- 
haps one  and  a  half  or  two  inches.  The  bladder  will  now 
be  felt  at  the  bottom  of  the  wound  as  a  soft  fluctuatmg 
tumor,  still  coA^ered,  however,  by  areolar  tissue,  which 
may  be  divided  with  a  few  touches  of  the  knife  or  separated 
with  the  handle  of  the  scalpel ;  but  the  areolar  tissue  con- 


85  TUMORS   OF    THE    BLADDER. 

nection  between  the  bladder  and  symph3^sis  should  be  lett 
as  much  as  possible  intact,  because  it  forms  the  best  barrier 
against  the  infiltration  of  urine  or  pus.  The  bladder  being- 
now  fairly  exposed,  it  should  be  secured  by  ligature  or 
transfixed  by  a  tenacukim  before  it  is  opened ;  otherwise, 
when  the  incision  is  made  it  will  collapse  out  of  sight  and 
embarrass  the  surgeon  in  the  succeeding  steps  of  the 
operation.  The  bladder  being  held  in  position,  a  vertical 
incision  is  made,  the  margins  of  the  vesical  wound  held 
apart  while  the  tumor  is  drawn  out  if  possible,  and  removed 
either  by  avulsion,  ecraseur,  knife,  or  galvano-cautery. 
The  incision  in  the  bladder  should  be  as  small  as  possible, 
but  always  clean  cut  and  free  enough  for  eas}^  access  to 
the  growth,  as  stretching  of  the  wound  implies  more  or 
less  bruising  or  laceration  which,  when  the  edges  are 
brought  together,  will  correspondingly  interfere  with  the 
union  by  first  intention.  If  the  external  longitudinal  inci- 
sion affords  too  limited  a  field  for  operation,  the  wound 
may  be  enlarged  by  two  small,  transverse  cuts  immedi- 
ately above  the  pubes,  without  separating  entirely  the 
insertion  of  the  recti  muscles.  Billroth,  in  order  to  obtain 
sufficient  room,  was  obliged  to  divide  both  recti  at  their 
insertion.  But  this  is  to  be  avoided,  if  possible,  because 
such  wounds  require  a  longer  time  to  heal  and  are  apt  to 
lead  to  the  formation  of  abdominal  hernia. 

The  dangers  apprehended  from  supra-pubic  cj^stotomy 
are,  wounding  the  peritonEeum,  and  urinar}'  infiltration  of 
connective  tissue.  The  danger  of  wounding  the  peritonae- 
um is  not  so  great  as  is  generally  supposed.  Out  of  478 
cases  of  supra-pubic  lithotomy  collected  by  Dr.  Dulles 
{Amer.  Jour.  Med.  5^.,  July,  1875),  in  only  13  had  this  mem- 
brane been  wounded  and  of  these  3  cases  were  fatal.  Even 
for  the  removal  of  large  tumors,  the  bladder  can  be  so  dis- 
tended as  to  present  above  the  pubes,  and  opened  without 
endangering  the  peritonaeum.  Garson  {Edin.  Med.  Journ.y 
Oct.,  1 878)  has  shown  that  the  bladder  can  be  as  easily  raised 


TUMORS   OF    THE    BLADDER.  g? 

above  the  symphysis  by  distending  the  rectum  as  by  in- 
jecting the  bladder,  and  that,  in  case  where  it  is  not  advis- 
able to  distend  the  bladder  to  a  large  size,  distention  of 
the  rectum  by  a  colpeurynter  is  all  that  is  required  to 
make  the  parts  suitable  for  the  operation.  Petersen,  of 
Kiel,  by  numerous  experiments,  substantiates  these  ob- 
servations, and  finds  that,  with  the  bladder  and  rectum 
moderately  distended,  the  line  of  reduplication  of  the 
peritongeum,  as  shown  by  measurements  on  the  cadaver,  is 
thus  displaced  upward  to  the  distance  of  about  five  and 
one-half  centimetres,  and  can  thus  be  kept  out  of  the  way 
of  injur}^  In  children,  it  will  be  remembered  the  bladder 
is  almost  an  abdominal  viscus  ;  but  if  it  is  desirable  to  dis- 
tend the  rectum,  this  can  be  done  with  one  or  two  sponges, 
previously  attached  to  a  string,  to  prevent  them  from 
passing  beyond  reach. 

With  reference  to  the  question  of  urinary  infiltration, 
this  is  a  danger  to  be  apprehended  as  well  after  perineal 
as  after  supra-pubic  cystotomy ;  but  the  danger  of  septic 
infection  is,  perhaps,  less  after  epicystic  infiltration,  be- 
cause it  is  less  confined  and  more  accessible  to  our  inter- 
ference than  when  the  urine  has  infiltrated  the  peri-pro- 
static  and  cirumrectal  areolar  tissue. 

The  prevention  of  urinary  infiltration  involves  the  con- 
sideration as  to  the  best  way  of  dealing  with  the  vesical 
wound.  Shall  it  be  stitched  or  shall  it  be  left  open? 
Both  methods  have  their  strong  advocates,  and  both  have 
shown  excellent  results.  If  we  turn  to  our  present  expe- 
rience in  epicystotomy  for  the  removal  of  tumors,  we  find, 
on  the  one  hand,  the  success  of  Billroth,  by  the  open 
method,  and,  on  the  other  hand,  the  failures  of  Volkmann 
and  Marcacci,  by  the  closed  method.  Although  Volk- 
mann operated  in  a  manner  similar  to  Billroth  in  making 
the  preliminary  perineal  incision,  in  his  case,  as  in  Mar- 
cacci's,  purulent  infiltration  and  peritonitis  occurred  from, 
as  it  is  said,  imperfect  closure  of  the  vesical  wound. 


38  TUMORS   OF   THE   BLADDER. 

Prof.  Trendelenburg,  Rostock  {Berlin.  Klin.  Wochenschr .^ 
No.  I,  8i),  reports  four  successful  cases  of  supra-pubic 
lithotomy,  which  he  treated  by  the  open  method  with  ab- 
dominal decubitus.  At  the  completion  of  the  operation,  he 
washes  out  thoroughly  the  wound  and  the  bladder  with 
carbolic  solution,  and  then  relies  altogether  on  the  efhcacy 
of  drainage,  which  he  secures  by  inserting  through  the 
wound  and  into  the  bladder  a  T-shaped  drainage  tube,  its 
peculiar  shape  preventing  its  falling  out,  and  employing 
the  abdominal  decubitus  on  air  cushions.  He  considers 
infiltration  of  urine  impossible  under  this  management. 

On  the  other  hand,  excellent  results  have  been  attained 
after  the  high  operation  for  stone  with  stitching  of  the 
vesical  wound.  Although  we  have  been  unable  to  obtain 
statistics,  our  German  brethren,  especially,  appear  just 
now  to  have  a  predilection  for  this  particular  procedure, 
and  we  have  every  reason  to  expect  that  with  good 
depending  drainage  and  thorough  Listerism,  many  a  good 
result  will  follow  the  same  operation  for  the  removal  of 
tumors.  The  time,  however,  has  not  yet  come  when 
it  would  be  judicious  to  express  a  positive  opinion  as  to 
the  safest  method  of  dealing  with  the  vesical  wound  ;  we 
must  await  further  experience.  But  it  will,  no  doubt,  be 
impracticable  to  adopt  a  uniform  practice  in  all  cases. 
Among  other  things,  we  shall  have  to  be  governed  much 
by  the  condition  of  the  vesical  walls.  In  one  of  my  own 
cases,  for  instance,  the  vertex  of  the  bladder  had  become 
so  attenuated  by  distention  from  blood-clots  that,  had  the 
viscus  been  opened  from  above,  a  perfectly  water-tight 
closure  of  the  wound  by  sutures  could  not,  I  am  convinced, 
have  been  accomplished. 

As  an  absolute  water-tight  closure  of  the  vesical  wound 
is  a  conditio  sine  qua  izon,  to  union  by  first  intention,  as 
soon  as  the  sutures  are  applied,  the  bladder  should  be 
moderately  distended  with  water  to  see  that  this  has  been 
accomplished. 


"  TUMORS  OF  THE  BLADDER.  89 

With  the  view  of  preventing  urinary  infiltration,  Vidal 
de  Cassis  suggested  dividing  the  supra-pubic  cystotomy 
into  two  separate  operations :  the  first  to  consist  in  mak- 
ing the  abdominal  section  down  to  the  bladder,  and  some 
days  after  the  establishment  of  surrounding  adhesive  in- 
flammation, to  open  the  bladder.  Nelaton  is  said  to  have 
once  operated  in  this  manner,  but  the  patient,  seventy- 
eight  years  old,  had  so  much  pain  that  the  bladder  had  to 
be  opened  on  the  third  day.  I  cannot  find  that  this  pecu- 
liar method  has  since  been  repeated. 

T.  Gaillard  Thomas  has  very  recently  made  a  success 
of  clamping  the  lips  of  the  vesical  incision  between  those 
of  the  abdominal  wound,  and  it  may  be  that  we  have  by 
this  method  the  prospect  of  better  results  than  those 
hitherto  obtained  by  sewing  up  the  opening  and  return- 
ing the  repaired  viscus  to  the  pelvic  cavity.  This  new 
procedure  was  effected  on  the  occasion  of  a  laparotomy, 
performed  on  a  lady,  aged  thirty-eight,  for  the  removal 
of  a  large  multilocular  ovarian  cyst.  The  abdominal 
walls  being  laid  open  to  the  extent  of  about  three  and 
one-half  inches  in  the  median  line,  Thomas  found  the 
bladder  greatly  expanded  over,  and  extensively  attached 
to  the  anterior  surface  of  the  ovarian  tumor.  He  attempted 
to  define  this  attachment  by  passing  a  long  catheter  into 
the  bladder,  but  the  tumor  pressed  so  firmly  against  the 
pubes  that  it  could  not  be  introduced  beyond  that  point. 
He  now  made  an  incision  through  the  anterior  wall  of  the 
bladder,  and  passing  the  index  finger  of  the  left  hand,  he 
was  able  for  the  first  time  to  determine  the  upper  limit  of 
the  adherent  viscus,  and  succeeded  in  separating  it  from 
its  extensive  attachments.  After  this  the  tumor  was  re- 
moved in  the  usual  way ;  its  pedicle  cut,  ligated,  and 
returned  to  the  peritoneal  cavity.  With  Peaslee's  needle, 
he  applied  silver  sutures  to  the  abdominal  wound,  until 
the  same  was  closed  from  above  downwards  to  the  open- 
ing in  the  bladder.     He  now  passed  the  needle  through 


go  TUMORS   OF   THE   BLADDER. 

the  abdominal  wall ;  then  through  one  vesical  wall,  through 
the  other,  and,  lastly,  through  the  opposite  abdominal 
wall,  and  so  continued  to  do,  until  the  whole  opening  in 
the  bladder  was  traversed  by  sutures.  The  sutures  were 
then  twisted,  care  being^taken  to  lift  the  bladder  well  up 
to  the  surface,  and  the  operation  was  completed.  A  Sims' 
sigmoid  catheter  was  kept  in  the  bladder.  The  sutures 
were  removed  on  the  tenth  day,  and  the  case  progressed 
favorably  until  the  fourteenth  day,  when  a  slight  oozing  of 
urine  was  discovered  from  an  opening  not  larger  than  a 
cambric  needle  in  the  line  of  the  incision  ;  but  this  minute 
opening  was  closed  by  the  application  of  an  additional  su- 
ture, and  at  the  end  of  three  months,  the  patient  went 
home  entirely  well. 

If  after  epicystotoray  the  drainage  of  the  bladder  is  to  be 
secured  by  the  retention  of  a  catheter  per  urethram,  the 
method  suggested  by  Chiene,  of  Edinburgh,  for  the  cure 
of  obstinate  urinary  fistulcC — the  value  of  which  I  have  re- 
cently had  opportunity  to  verify — commends  itself  for 
adoption  also  after  supra-pubic  cystotomy.  It  is  as  follows : 
A  flexible,  perfectly  smooth-eyed  catheter  is  introduced 
and  fixed  to  the  penis  with  sticking-plaster.  Care  is  taken 
that  the  eye  of  the  instrument  is  just  within  the  neck  of  the 
bladder.  To  this  catheter  an  India-rubber  tube  is  fixed,  of 
sufficient  length  to  reach,  without  being  strained,  over  the 
side  of  the  bed  to  the  floor.  It  then  passes  into  a  bottle. 
The  bottle  and  tube  are  filled  with  carbolized  water  before 
attaching  the  apparatus  to  the  catheter.  Care  is  taken 
that  no  air  can  get  in  at  any  of  the  joints.  It  is  well  to 
introduce  a  piece  of  glass-tubing  at  a  convenient  part  for 
observing  the  direction  of  the  flow.  In  order  to  keep  the 
India-rubber  tube  steady  in  the  bottle,  a  piece  of  glass- 
tubing  is  attached  to  its  extremity.  If  the  glass  tube  ex- 
tends beyond  the  neck  of  the  bottle,  any  folding  of  the 
India-rubber  tube  at  this  point  will  be  prevented.  A 
siphon  action  is   in  this  way  established,  with  a  suction 


TUMORS    OF    THE    BLADDER.  gi 

power,  the  strength  of  which  depends  on  the  height  of  the 
column  of  water,  and  which  will  draw  the  urine  into  the 
eye  of  the  catheter  as  it  passes  drop  by  drop  from  the 
openings  of  the  ureters  into  the  bladder,  and  a  constant 
slow  current  of  water  will  pass  along  the  tube  into  the 
bottle.  The  bottle  is  allowed  to  overflow  into  a  basin, 
which  as  it  fills  can  be  emptied  without  displacing  the 
apparatus.  The  bladder  is  kept  constant!}'  empty.  Care 
must  be  taken  not  to  have  too  great  a  fall,  or  the  suction 
of  a  piece  of  mucous  membrane  into  the  eye  of  the  cathe- 
ter will  cause  uneasiness  and  plug  the  catheter.  The 
height  of  the  hospital  bed  is  generally  sufficient,  and  in 
some  cases  even  a  less  height  is  all  that  is  required. 

Palliative  Treatinent. 

With  regard  to  the  treatment  of  malignant  tumors,  there 
is  no  reason  why  a  timelj"  operation  may  not,  in  certain 
cases,  prolong  life ;  but,  as  a  rule,  cancerous  tumors  will 
admit  at  most  of  but  palliative  treatment,  such  as  alleviation 
of  pain,  controlling  hemorrhage,  and  making  life  as  endur- 
able as  possible.  Pain,  irritation,  and  spasm  should  be 
allayed  as  completely  as  possible  by  the  free  administra- 
tion of  anodynes,  as  by  so  doing  we  not  only  afford  the 
necessary  relief  from  suffering,  but  keeping  both  mind  and 
body  in  a  condition  of  quiet  and  rest,  we  diminish  greatly 
the  tendency  to  hemorrhage.  Conditions  that  tend  to  the 
determination  of  blood  to  the  pelvic  organs  should  be 
avoided,  the  patient  should  lie  with  the  pelvis  somewhat 
elevated  and  the  bowels  must  be  kept  free.  As  to  the 
efficacy  of  ergot,  gallic  acid,  turpentine,  iron,  sulphuric 
acid,  matico,  alum,  etc.,  in  restraining  hemorrhage  from 
tumors  of  the  bladder,  we  are  not  enthusiastic ;  they  seem 
to  have  occasionally  served  their  purpose,  but  they  must 
always  be  administered  freely,  and  even  then  the}-  will  often 
disappoint.  Local  astringents  and  styptics  are  of  much 
more  value.     Cold-water  irrigation,  ice-bags  applied  to 


g2  TUMORS   OF   THE   BLADDER, 

the  hypogastrium  or  perinasum,  or  ice  introduced  into  the 
rectum  or  vagina  is  often  of  much  service.  The  topical 
application  of  sol.  zinci  chloridi,  argent,  nitrate,  iron,  alum, 
etc.,  have  proved  of  marked  success  in  checking  hemor- 
rhage. In  injecting  the^  bladder,  it  must  always  be  re- 
membered that  the  greatest  care  is  to  be  taken  during 
catheterization  to  avoid  touching  or  bruising  the  tumor  with 
the  instrument,  which  always  provokes  more  or  less  hemor. 
rhage,  and  may  thwart  the  very  object  it  is  sought  to 
attain.  In  the  introduction  of  the  instrument,  the  eye  of 
the  catheter  should  reach  just  within  the  vesical  orifice  and 
no  further. 

In  some  cases,  the  bladder  may  be  more  advantageously 
injected  by  means  of  a  fountain  syringe  or  rubber-bag 
syringe  without  the  aid  of  a  catheter,  and  simply  by  hy- 
drostatic pressure,  as  recommended  by  Zeissl.  The  pa- 
tient is  placed  in  the  recumbent  posture,  with  nates  raised; 
the  penis  is  brought  up  against  the  abdominal  wall  without 
undue  stretching;  the  nozzle  of  the  irrigator  is  introduced 
into  the  urethra  and  there  held  in  such  a  manner  that  re- 
gurgitation of  fluid  from  the  meatus  cannot  take  place;  the 
stopcock  is  opened  and  the  urethra  becomes  distended;  the 
sphincters  yield,  and  the  fluid  enters  the  bladder.  Hunter 
McGuire,  Professor  of  Surgery  in  Virginia,  mentions  a  case 
of  malignant  vascular  tumor  of  the  bladder,  where  the  soft 
gum  catheter  gave  rise  to  serious  bleeding  and  to  severe 
urethral  fever.  Nothing  gave  the  patient  so  much  comfort 
as  the  use  of  this  rubber-bag  syringe.  He  not  only  em- 
ployed it  morning  and  night  to  wash  out  the  bladder  of 
the  blood,  mucus  and  pus  that  collected  there  ;  but 
sometimes  an  injection  of  simple  warm  water  stopped  the 
pain  and  vesical  tenesmus  better  than  anything  else.  Sev- 
eral times  the  bleeding  was  stopped  by  adding  alum  to  the 
water.  I  have  myself  practised  this  method  of  injecting 
the  bladder  in  many  cases  during  the  past  few  years,  and 
often  with  much  less  pain  and  discomfort  to  the  patient 
than  when  the  catheter  was  used. 


TUMORS   OF   THE   BLADDER.  g. 

Conclusions. 

From  the  foregoing  observations  and  statistics  1  think 
we  may  formulate  our  conclusions  as  follows : 

I  St.  In  a  few  remarkable  instances  in  the  case  of  women, 
apparent  recovery  seems  to  have  resulted  from  a  sponta- 
neous expulsion  of  growths  from  the  bladder.  But  in 
general  it  may  be  said  that  tumors  of  the  bladder,  if  unin- 
terfered  with,  are  inevitably  fatal.  And,  although  they 
may  exist  for  several  years  without  creating  much  distress, 
a  fatal  termination  almost  invariably  ensues  in  a  few  weeks 
or  months  from  the  outbreak  of  active  symptoms. 

2d.  Death  results  most  frequently  from  hemorrhage,  and 
from  the  effects  of  mechanical  obstruction  to  the  outflow 
of  urine.  Hence  the  indication  would  be  to  remove  the 
growth  while  the  general  condition  of  the  patient  is  yet 
.favorable  for  an  operation  ;  before  the  subject  has  become 
exhausted  from  loss  of  blood,  or  the  kidneys  and  bladder 
have  become  so  much  diseased  as  to  make  recovery  im- 
possible, even  in  the  event  of  the  successful  extirpation  of 
the  growth. 

3d.  In  women,  because  of  the  accessibility  of  the  blad- 
der to  direct  exploration,  there  is  no  excuse  for  temporiz- 
ing, and  the  surgeon  should  lose  no  time  in  acquiring  an 
exact  knowledge  as  to  the  existence,  nature,  etc.,  of  the 
tumor,  and,  if  practicable,  attempt  its  removal  as  early  as 
possible. 

4th.  The  results  thus  far  attained  by  surgical  interfer- 
ence, in  the  cases  of  women,  could  scarcely  be  more  satis- 
factory, and  excepting  one  instance  in  which  the  bladder 
was  accidentally  perforp.ted,  it  does  not  appear  that  the 
fatal  termination  was  precipitated  by  the  operation  in  any 
of  the  cases. 

5th.  In  the  male,  the  propriety  of  operative  interference 
must  necessarily  always  be  a  more  serious  question ;  be- 
cause of  the  occasional  uncertainty  of  diagnosis,  and  because 


g.  TUMORS   OF   THE   BLADDER. 

of  the  gravity  of  the  undertaking  necessary  for  the  removal 
of  the  growth.  Nevertheless  the  results,  thus  far  attained 
by  operation,  are  most  encouraging  and  in  every  way  jus- 
tify a  repetition  of  the  same. 

6th.  From  a  number  of  autopsies  made,  we  learn  that  the 
successful  operations  might  have  been  multiplied  first  in 
those  cases  in  which  no  operation  was  attempted,  although 
the  growths  could  have  been  easily  removed  and  with  ap- 
parently every  prospect  of  success ;  and  again  in  those  in 
which  the  operation  was  too  long  deferred  and  which,  it  is 
reasonable  to  assume,  would  have  terminated  successfully, 
had  the  same  been  undertaken  at  an  earlier  period. 

7th.  Given  a  positive  diagnosis  of  tumor,  the  absence  of 
severe  secondary  symptoms  should  be  no  excuse  for  de- 
ferring the  operation.  On  the  contrary,  the  earlier  the 
growth  is  removed  the  better  the  prospects  of  complete 
recovery.  With  a  healthy  bladder  and  kidney,  cysto- 
tomy is  not  so  dangerous  an  operation  as  to  warrant 
any  delay. 

8th.  Evidence  strongly  pointing  to  the  existence  of  a 
tumor  with  severe  catarrhal  symptoms  or  with  spasm  of 
the  bladder  and  much  suffering,  will  often  justify  an  oper- 
ation; for,  if  a  tumor  is  found,  its  extirpation  will  afford 
the  only  chance  for  life ;  and  if  no  growth  exists,  or  the 
bladder  is  occupied  by  an  irremovable  cancer,  the  cystot- 
omy may  at  least  afford  temporary  relief  from  suffering. 


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